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Sung C, Wang J, Chang J, Wong AK. Review of treatment strategies after lymphadenectomy: from molecular therapeutics to immediate microsurgical lymphatic reconstruction. J Vasc Surg Venous Lymphat Disord 2024:101844. [PMID: 38316291 DOI: 10.1016/j.jvsv.2024.101844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 01/25/2024] [Accepted: 01/28/2024] [Indexed: 02/07/2024]
Abstract
OBJECTIVE Lymphedema is a common complication of cancer treatment, such as lymphadenectomy and radiation therapy. It is a debilitating condition with pathologic tissue changes that hinder effective curative treatment and jeopardize patients' quality of life. Various attempts to prevent the development of lymphedema have been made, with improvements in the incidence of the pathology. However, it is still prevalent among survivors of cancer. In this paper, we review both molecular therapeutics and immediate surgical lymphatic reconstruction as treatment strategies after lymphadenectomy. Specifically, we discuss pro-lymphangiogenic molecules that have proved efficient in animal models of lymphedema and clinical trials, and review currently available microsurgical techniques of immediate lymphatic reconstruction. METHODS A literature search was conducted in PubMed, Embase, Cochrane Library, and Google Scholar through May 2022. Searches were done separately for molecular therapeutics and microsurgical techniques for immediate lymphatic reconstruction. Search terms used for (1) non-surgical methods include 'lymphangiogenesis,' 'lymphedema,' 'growth factor,' and 'gene therapy.' Search terms used for (2) surgical methods include 'lymphedema,' 'lymph node excision,' 'lymphatic vessels,' 'primary prevention,' and 'microsurgery.' RESULTS Various pro-lymphangiogenic factors with therapeutic potential include VEGF-C, VEGF-D, HGF, bFGF, PDGF, IGF, Retinoic acid, Ang-1, S1P, TLR4, and IL-8. Microsurgical lymphatic reconstruction for prevention of secondary lymphedema includes lymphovenous anastomosis, vascularized lymph node flap transfer, and lymph-interpositional flap transfer, with promising clinical outcomes. CONCLUSIONS With growing knowledge of the lymphangiogenic pathway and lymphedema pathology and advances in microsurgical techniques to restore lymphatic channels, molecular and surgical approaches may represent a promising method for primary prevention of lymphedema.
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Affiliation(s)
- Cynthia Sung
- Division of Plastic Surgery, City of Hope National Medical Center, Duarte, CA; Keck School of Medicine of USC, Los Angeles, CA
| | - Jin Wang
- Division of Plastic Surgery, City of Hope National Medical Center, Duarte, CA
| | - Jeff Chang
- Division of Plastic Surgery, City of Hope National Medical Center, Duarte, CA
| | - Alex K Wong
- Division of Plastic Surgery, City of Hope National Medical Center, Duarte, CA.
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Mitsui K, Narushima M, Danno K, Ishiura R, Banda CH. Intra-lymphocele microsurgical identification of causative afferent vessels for effective lymphaticovenular anastomosis in lymphocele treatment: A case report. Microsurgery 2024; 44:e31002. [PMID: 36571804 DOI: 10.1002/micr.31002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 11/22/2022] [Accepted: 12/14/2022] [Indexed: 12/27/2022]
Abstract
Lymphoceles are an important complication of pelvic and abdominal surgery with a reported incidence of 11%-88%. Conventional treatment includes compression, puncture aspiration, sclerotherapy, and ligation but recurrence is not uncommon and is difficult to treat. Recently, microsurgical lymphaticolymphatic anastomosis, lymphaticovenular anastomosis (LVA) and reconstruction of lymphatic circulation with flaps are increasingly being utilized for lymphocele treatment. Effective microsurgical treatment requires precise identification of the causative afferent vessels for the most efficient circulatory by-pass. However, direct identification of these vessels using traditional lymphoscintigraphy and near infrared lymphography is challenging and often not possible. We report the case of a 55-year-old woman who presented with bilateral inguinal lymphoceles and lymphedema following pelvic surgery for vulvovaginal cancer. Bilateral multiple LVAs of the lower extremities were performed and the lower limb circumferences reduced postoperatively, however both lymphoceles still persisted. The patient was successfully treated by approaching the lymphoceles from inside the lymphocele cavity. The causative afferent lymph vessels were directly identified microsurgically by gentle pressure on the inner wall and causative afferent lymph vessel lymphaticovenular anastomosis was performed. The lymphoceles resolved promptly after surgery without complications, and no recurrence was observed on 5 years follow-up. This case report presents an innovative microsurgical approach to lymphocele treatment, including examination and techniques to identify the causative afferent lymphatic vessels for effective anastomosis. We report this case to demonstrate the importance of lymphatic vessel selection in the microsurgical treatment of lymphocele.
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Affiliation(s)
- Kohei Mitsui
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, Tsu, Japan
| | - Mitsunaga Narushima
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, Tsu, Japan
| | - Kanako Danno
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, Tsu, Japan
| | - Ryohei Ishiura
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, Tsu, Japan
| | - Chihena H Banda
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, Tsu, Japan
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Jansen A, de Jong A, Hoogendam JP, Baeten IGT, Jürgenliemk-Schulz IM, Zweemer RP, Gerestein CG. Lymphocele following lymph node dissection in cervical and endometrial cancer: A systematic review and meta-analysis. Gynecol Oncol 2023; 170:273-281. [PMID: 36738486 DOI: 10.1016/j.ygyno.2023.01.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 12/31/2022] [Accepted: 01/17/2023] [Indexed: 02/05/2023]
Abstract
OBJECTIVES The purpose of this systematic review and meta-analysis was to evaluate the proportion and risk factors of lymphoceles and symptomatic lymphoceles after PLND in early-stage cervical and early-stage high or high-intermediate risk endometrial cancer. METHODS Studies reporting on the proportion of lymphocele after PLND were conducted in PubMed, Embase and Cochrane Library. Retrieved studies were screened on title/abstract and full text by two reviewers independently. Quality assessment was conducted using the Newcastle Ottowa Scale and the Cochrane risk-of-bias tool. Proportion of lymphocele and possible risk factors were pooled through random-effects meta-analyses. RESULTS From the 233 studies retrieved, 24 studies were included. The pooled proportion of lymphocele was 14% and of symptomatic lymphocele was 3%. Routinely performing diagnostics was associated with a significantly higher proportion of lymphocele compared to diagnostics performed on indication (21% versus 4%, p < 0.01). Laparotomic surgical approach led to a significantly higher proportion of lymphoceles than laparoscopic surgical approach (18% versus 7%, p = 0.05). The proportion of lymphocele was significantly higher when >15% of the study population underwent additional paraaortic lymph node dissection (PAOLND) opposed to <15% (15% versus 3%, p < 0.01). A mean number of lymph nodes dissected of <21 resulted in a significantly higher pooled proportion of lymphoceles opposed to when the mean number was 21 or higher (19% versus 5%, p = 0.02). Other risk factors analysed were BMI, lymph node metastasis, adjuvant radiotherapy and follow up. There was no sufficient data to detect significant risk factors for the development of symptomatic lymphoceles. CONCLUSION The pooled proportion of lymphocele was 14% of which symptomatic lymphoceles occurred in 3%. Significant risk factors for the total proportion of lymphoceles were laparotomic approach, decreased number of lymph nodes dissected and additional PAOLND.
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Affiliation(s)
- A Jansen
- Department of Gynecologic Oncology, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - A de Jong
- Department of Gynecologic Oncology, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - J P Hoogendam
- Department of Gynecologic Oncology, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - I G T Baeten
- Department of Gynecologic Oncology, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - I M Jürgenliemk-Schulz
- Department of Radiation Oncology, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - R P Zweemer
- Department of Gynecologic Oncology, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - C G Gerestein
- Department of Gynecologic Oncology, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
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Hwang JH, Kim BW. The incidence of postoperative symptomatic lymphocele after pelvic lymphadenectomy between abdominal and laparoscopic approach: a systemic review and meta-analysis. Surg Endosc 2022; 36:7114-7125. [PMID: 35467142 DOI: 10.1007/s00464-022-09227-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 03/29/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the risks of symptomatic lymphocele after pelvic lymphadenectomy between the laparoscopic and abdominal approach in uterine cervical and endometrial cancer. METHODS We searched Ovid Medline, Ovid EMBASE, and the Cochrane library through April 2020. We selected the comparative studies contained information on symptomatic lymphoceles in postoperative complications. All articles searched were independently reviewed and selected by two researchers. A meta-analysis was performed using the Stata MP version 16.0 software package. RESULTS A total of 33 eligible clinical trials were ultimately enrolled in this meta-analysis. When all studies were pooled, the odds ratios (OR) of the laparoscopic approach for the risk of symptomatic lymphoceles compared to the abdominal approach was 0.58 [95% confidence interval (CI): 0.42-0.81, p = 0.022, I-squared = 0.0%]. The risk of postoperative symptomatic lymphoceles in the laparoscopic group tended to decrease over time in the cumulative meta-analysis. In the subgroup analysis, there was no evidence for an association between cancer type, quality of the study methodology, hysterectomy type, and postoperative symptomatic lymphoceles. However, in a recently published article, being overweight (body mass index ≥ 25) and studies conducted in oriental area were associated with a lower incidence of postoperative symptomatic lymphoceles. CONCLUSION Laparoscopic lymphadenectomy was associated with a significantly lower risk of postoperative symptomatic lymphoceles than abdominal lymphadenectomy (PROSPERO registration number: CRD 42,020,187,165).
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Affiliation(s)
- Jong Ha Hwang
- Department of Obstetrics and Gynecology, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Seo-Gu Incheon Metropolitan City, Simgokro 100 Gil 25, Incheon, 22711, South Korea.
| | - Bo Wook Kim
- Department of Obstetrics and Gynecology, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Seo-Gu Incheon Metropolitan City, Simgokro 100 Gil 25, Incheon, 22711, South Korea
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Biologically active lipids in the regulation of lymphangiogenesis in disease states. Pharmacol Ther 2021; 232:108011. [PMID: 34614423 DOI: 10.1016/j.pharmthera.2021.108011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/31/2021] [Accepted: 09/01/2021] [Indexed: 02/06/2023]
Abstract
Lymphatic vessels have crucial roles in the regulation of interstitial fluids, immune surveillance, and the absorption of dietary fat in the intestine. Lymphatic function is also closely related to the pathogenesis of various disease states such as inflammation, lymphedema, endometriosis, liver dysfunction, and tumor metastasis. Lymphangiogenesis, the formation of new lymphatic vessels from pre-existing lymphatic vessels, is a critical determinant in the above conditions. Although the effect of growth factors on lymphangiogenesis is well-characterized, and biologically active lipids are known to affect smooth muscle contractility and vasoaction, there is accumulating evidence that biologically active lipids are also important inducers of growth factors and cytokines that regulate lymphangiogenesis. This review discusses recent advances in our understanding of biologically active lipids, including arachidonic acid metabolites, sphingosine 1-phosphate, and lysophosphatidic acid, as regulators of lymphangiogenesis, and the emerging importance of the lymphangiogenesis as a therapeutic target.
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Zeng W, Wang R, Ying W, Xu W, Zhao X. Impact on lower limb lymphedema of pelvic lymphadenectomy with external iliac lymph nodes left-opened distal lymphatics technique. INT ANGIOL 2020; 40:143-149. [PMID: 33300763 DOI: 10.23736/s0392-9590.20.04486-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The aim of this study was to investigate the effect of maintaining opened distal lymphatic vessels of external iliac lymph nodes on lymphedema and lymphocyst formation of lower limbs after pelvic lymphadenectomy. METHODS Prospective single center observational study was carried out in 83 patients with gynecological malignancies who underwent pelvic lymphadenectomy. During the operation, the distal lymphatic vessels of the external iliac lymph nodes were cut off by an ultrasound scalpel or scissors, and the proximal end was closed by bipolar coagulation. The patients were re-examined by a physical examination, ultrasound examination and inquiry of the symptoms within 2 years after the operation to check whether they had lower limb lymphedema and to analyze the presence of lymphedema and lymphocyst of lower limbs and the risk. RESULTS The incidence of lower limb lymphedema (LLL) was 21.6% (18/83). Among the patients with LLL, 5.5% (1/18) was diagnosed with stage 0 according to the criteria of International Society of Lymphology, 83.3% (15/18) with stage 1, and 11.1% (2/18) with stage 2. Presently, there was no lymphedema diagnosed at stage 3. The incidence of lymphocyst was 7.2% (6/83). Among the patients with lymphocyst, 3.6% (3/83) occurred 1 month after operation, 2.4% (2/83) occurred 3 months after operation and 1.2% (1/83) occurred 6 months after operation. Patients with radiotherapy and abdominal infection were more likely to suffer from LLL (P<0.05). CONCLUSIONS Maintaining opened distal lymphatic vessels of external iliac lymph nodes during pelvic lymphadenectomy is feasible, safe and with a 21.6% and 7.2% of potential lymphedema and lymphocists, respectively.
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Affiliation(s)
- Wenjie Zeng
- Department of Gynecology, Zhejiang Provincial People's Hospital, Hangzhou Medical College, People's Hospital, Hangzhou, China
| | - Rui Wang
- Bengbu Medical College, Bengbu, China
| | - Weijia Ying
- Zhejiang Chinese University Hospital, Hangzhou, China
| | - Wanwan Xu
- The Fourth Affiliated Hospital of Zhejiang University School of Medicine, Yiwu, China
| | - Xiaofeng Zhao
- Women's Hospital School of Medicine Zhejiang University, Hangzhou, China -
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Gezer Ş, Pulur A, Yücesoy İ. Application of thrombin gel matrix for the prevention of lymphocele in patients with endometrial cancer: A prospective randomized trial. J Gynecol Obstet Hum Reprod 2020; 50:101994. [PMID: 33217600 DOI: 10.1016/j.jogoh.2020.101994] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 11/12/2020] [Accepted: 11/13/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate a thrombin gel matrix (TGM), Floseal, for the prevention of lymphocele in patients with endometrial cancer who underwent pelvic lymphadenectomy. METHODS A total of 79 consecutive patients with endometrial cancer were randomly allocated to one of two groups: the TGM group and control group. After completion of the lymphadenectomy, 5 mL of Floseal was applied to the bilateral pelvic sidewalls, especially the femoral canal, obturator, and common iliac vessels areas. Computed tomography scans were obtained for lymphocele evaluation 2 months after the surgery. RESULTS Three patients from the TGM group, and four patients from the control group were lost during follow-up, and data from 36 participants from each group were analyzed. As the primary outcome, lymphocele developed in 12 patients in both groups (33 %). There was no significant difference between the groups in terms of lymphocele and symptomatic lymphocele development. Lymphocele localization was also not different between the two groups, but the diameter of the lymphoceles detected in the TGM group was significantly greater (p = 0.021). The mean drainage days was significantly shorter in the TGM group (p = 0.015). The amount of drainage was also less in the TGM group, but the difference was not statistically significant. CONCLUSION Thrombin gel matrix applied to the pelvic sidewalls does not reduce the incidence of symptomatic or asymptomatic lymphoceles after pelvic lymphadenectomy in endometrial cancer. However, it can reduce the amount of drainage and the number of drainage days so it can help to shorten hospitalization.
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Affiliation(s)
- Şener Gezer
- Kocaeli University School of Medicine, Department of Gynecologic Oncology, Turkey.
| | - Alparslan Pulur
- Kocaeli University School of Medicine, Department of Gynecologic Oncology, Turkey
| | - İzzet Yücesoy
- Kocaeli University School of Medicine, Department of Gynecologic Oncology, Turkey
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Rebegea LF, Stoleriu G, Manolache N, Serban C, Craescu M, Lupu MN, Voinescu DC, Firescu D, Ciobotaru OR. Associated risk factors of lower limb lymphedema after treatment of cervical and endometrial cancer. Exp Ther Med 2020; 20:181. [PMID: 33101471 PMCID: PMC7579779 DOI: 10.3892/etm.2020.9311] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/04/2020] [Indexed: 11/30/2022] Open
Abstract
The scope of the study was to identify the associated risk factors of lower limb lymphedema development in cervical and endometrial cancer patients. We retrospectively analysed 326 patients: 186 cases (57.06%) with cervical cancer and 140 cases (42.94%) with endometrial cancer were treated in Surgery, Radiotherapy, Oncology and Gynaecology Clinics of ‘St. Apostle Andrew’ Emergency Clinical Hospital Galati over 9 years. Adjuvant radiotherapy was performed in 83.57% of endometrial cancer cases. Adjuvant chemotherapy was performed in 45.16% of cervical cancer cases. Over 10 lymph nodes were removed in 74.73% of cervical cancer patients. Incidence of lymphedema was 15.05% in cervical cancer patients and 10% in endometrial cancer patients, P=0.06. Analysed risk factors for lower limb lymphedema occurrence were: Age, disease stage, radiotherapy, number of invaded lymph nodes (for cervical cancer patients), number of removed lymph nodes (for cervical cancer patients) and obesity. Multivariate analysis for associated risk factors of lower limb lymphedema development in cervical cancer showed that number of removed lymph nodes, OR=2.109 (0.907-4.903), P<0.0001, number of lymph nodes with metastasis, OR=1.903 (0.253-4.332), P=0.004 and obesity, OR=1.713 (0.226-2.967), P=0.006 were found as statistically significant risk factors for lower limb lymphedema onset. For endometrial cancer patients, obesity, OR=1.518 (0.721-2.75), P=0.0003, was the only associated risk factor with statistical significance for the lower limb lymphedema development. Lower limb lymphedema represents one of the adverse reactions of multimodal treatment in gynaecological cancers which affects patient's quality of life. Lower limb lymphedema occurrence is related with number of risk factors, the most important being removed lymph nodes, obesity and radiotherapy.
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Affiliation(s)
- Laura Florentina Rebegea
- Department of Radiotherapy and Oncology, 'St. Apostle Andrew' County Emergency Clinical Hospital, 800179 Galați, Romania.,Clinical Department, Faculty of Medicine and Pharmacy, 'Dunarea de Jos' University, 800008 Galati, Romania
| | - Gabriela Stoleriu
- Clinical Department, Faculty of Medicine and Pharmacy, 'Dunarea de Jos' University, 800008 Galati, Romania
| | - Nicuta Manolache
- Department of Pharmaceutical Sciences, Faculty of Medicine and Pharmacy, 'Dunarea de Jos' University, 800008 Galati, Romania
| | - Cristina Serban
- Second Surgery Clinic, 'St. Apostle Andrew' County Emergency Clinical Hospital, 800179 Galati, Romania.,Department of Surgery, Faculty of Medicine and Pharmacy, 'Dunarea de Jos' University, 800008 Galati, Romania
| | - Mihaela Craescu
- Department of Radiotherapy and Oncology, 'St. Apostle Andrew' County Emergency Clinical Hospital, 800179 Galați, Romania.,Department of Morphological and Functional Sciences, Faculty of Medicine and Pharmacy, 'Dunarea de Jos' University, 800008 Galati, Romania
| | - Mary-Nicoleta Lupu
- Department of Surgery, Faculty of Medicine and Pharmacy, 'Dunarea de Jos' University, 800008 Galati, Romania.,Anaesthesia and Intensive Care Clinic, 'St. Apostle Andrew' County Emergency Clinical Hospital, 800179 Galați, Romania
| | - Doina Carina Voinescu
- Clinical Department, Faculty of Medicine and Pharmacy, 'Dunarea de Jos' University, 800008 Galati, Romania
| | - Dorel Firescu
- Second Surgery Clinic, 'St. Apostle Andrew' County Emergency Clinical Hospital, 800179 Galati, Romania.,Department of Surgery, Faculty of Medicine and Pharmacy, 'Dunarea de Jos' University, 800008 Galati, Romania
| | - Oana Roxana Ciobotaru
- Clinical Department, Faculty of Medicine and Pharmacy, 'Dunarea de Jos' University, 800008 Galati, Romania
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Decreasing Lymphoid Fluid Accumulation During Lymph-Node Dissection. J Gynecol Surg 2019. [DOI: 10.1089/gyn.2018.0061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Weinberger V, Fischerova D, Semeradova I, Slama J, Cibula D, Zikan M. Ultrasound characteristics of a symptomatic and asymptomatic lymphocele after pelvic and/or paraaortic lymphadenectomy. Taiwan J Obstet Gynecol 2019; 58:266-272. [PMID: 30910151 DOI: 10.1016/j.tjog.2019.01.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2018] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE To describe the sonographic characteristics of a lymphocele after pelvic and/or paraaortic lymphadenectomy for gynecological malignancy, analyze and identify ultrasound characteristics related to the symptomatic and asymptomatic lymphoceles. MATERIALS AND METHODS This is a retrospective analysis of ultrasound examination data collected consecutively in patients after pelvic and/or paraaortic lymphadenectomy in one institution. We recorded the number of lymphoceles, localization, size; ultrasound morphology following International Ovarian Tumor Analysis group classification and symptoms. RESULTS We described and analyzed 227 lymphoceles (150 asymptomatic and 77 symptomatic) in 161 patients. The asymptomatic lymphocele is typically a thick-walled cystic lesion without vascularization, round and unilocular with anechoic or ground-glass content. The symptomatic lymphocele is typically an oval, or ovoid, unilocular lesion with low-level or anechoic content (ground glass content is unlikely to be present, p < 0.001) and the presence of debris and septations. The lymphocele size (p = 0.001), number of lymphoceles (>1) (p = 0.005), septa (p = 0.002), and debris (p < 0.001) were independent ultrasound features correlating to symptoms development. More than one lymphocele (p = 0.047), septations (p = 0.007) and presence of debris (p < 0.001) were independent ultrasound features correlated to infection. CONCLUSION Ultrasound features of symptomatic and asymptomatic lymphocele differ. The clues for lymphocele differential diagnosis are the history of lymphadenectomy and the finding cystic lesion with typically ultrasound features of lymphocele, adjacent to great pelvic vessels. Unique ultrasound features of lymphocele may help to distinguish from tumor relapse, hematoma, abscess, seroma or urinoma.
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Affiliation(s)
- Vit Weinberger
- Department of Obstetrics and Gynecology, Masaryk University, Faculty of Medicine, Jihlavska 20, 625 00, Brno, Czech Republic
| | - Daniela Fischerova
- Gynecological Oncology Center, Department of Obstetrics and Gynecology, Charles University - First Faculty of Medicine and General University Hospital, Apolinarska 18, 128 00 Prague, Czech Republic
| | - Ivana Semeradova
- Gynecological Oncology Center, Department of Obstetrics and Gynecology, Charles University - First Faculty of Medicine and General University Hospital, Apolinarska 18, 128 00 Prague, Czech Republic
| | - Jiri Slama
- Gynecological Oncology Center, Department of Obstetrics and Gynecology, Charles University - First Faculty of Medicine and General University Hospital, Apolinarska 18, 128 00 Prague, Czech Republic
| | - David Cibula
- Gynecological Oncology Center, Department of Obstetrics and Gynecology, Charles University - First Faculty of Medicine and General University Hospital, Apolinarska 18, 128 00 Prague, Czech Republic
| | - Michal Zikan
- Gynecological Oncology Center, Department of Obstetrics and Gynecology, Charles University - First Faculty of Medicine and General University Hospital, Apolinarska 18, 128 00 Prague, Czech Republic; Department of Obstetrics and Gynecology, Charles University - First Faculty of Medicine and Na Bulovce Hospital, Budinova 67/2, 181 00 Prague, Czech Republic.
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Predictors of Lymphoceles in Women Who Underwent Laparotomic Retroperitoneal Lymph Node Dissection for Early Gynecologic Cancer: A Retrospective Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16060936. [PMID: 30875912 PMCID: PMC6466375 DOI: 10.3390/ijerph16060936] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 03/03/2019] [Accepted: 03/12/2019] [Indexed: 12/20/2022]
Abstract
Background: Lymphoceles could represent a detrimental complication after retroperitoneal lymph node dissection. Our aim was to elucidate predictors of lymphoceles. Methods: Between 2011 and 2017, medical records of consecutive women who underwent laparotomic retroperitoneal lymph node dissection for FIGO stage I or II gynecologic cancer were reviewed. Results: A total of 204 women, including those with lymphoceles (n = 31) and symptomatic lymphoceles (n = 7), were reviewed. According to multivariable analysis, parity (odds ratio = 0.59, p = 0.003), adjuvant pelvic radiotherapy (odds ratio = 2.60, p = 0.039), and peritoneal nonclosure without pelvic drainage (odds ratio = 2.31, p = 0.048) were predictors of lymphoceles. In addition, parity (odds ratio = 0.73, p = 0.03), hypertension (odds ratio = 2.62, p = 0.02), and peritoneal partial closure with pelvic drainage (odds ratio = 0.27, p = 0.02) were predictors of complications. Conclusion: Low parity, adjuvant pelvic radiotherapy, and peritoneal nonclosure without pelvic drainage were associated with increased lymphocele formation. In addition, a lower complication rate was found in the peritoneal partial closure with pelvic drainage group; thus, peritoneal partial closure with pelvic drainage might be suggested for women who undergo laparotomic retroperitoneal lymph node dissection.
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Greater Omental Lymph Node Flap for Upper Limb Lymphedema with Lymph Nodes-depleted Patient. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1288. [PMID: 28507857 PMCID: PMC5426876 DOI: 10.1097/gox.0000000000001288] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 02/15/2016] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is available in the text. Background: The greater omentum is supplied by the right, middle, and left omental arteries, which arise from the right and left gastroepiploic arteries. All or part of the greater omentum can be harvested based on this blood supply for free tissue transfer. It has stimulated new interest in its use as the donor site in the treatment of lymphedema. For patients who have failed other management options or have limited peripheral lymph node donor sites, the greater omental lymph node flap may offer the best chance for lymphedema treatment. Methods: We report a 59-year-old woman with a history of left breast cancer who was treated with left modified radical mastectomy and axillary lymph node dissection and developed left upper extremity Grade IV lymphedema. She received vascularized groin lymph node transfer and lymphaticovenous anastomosis, but the result was not satisfactory. She also had nasopharyngeal cancer that was treated with radiotherapy to the head and neck, making use of the submental lymph nodes flap impossible. Due to a lack of other options of lymph node donor sites, the split greater omental lymph node flap (GOLF) was used. Results: After surgery, it showed an arm circumference reduction of 42.9% above the elbow and 36.4% below the elbow at an 8-month follow-up. There was no intraabdominal complication. Conclusions: The split GOLF has shown good results in a peripheral lymph node–depleted lymphedema patient. Using a laparoscopic technique for flap harvest has less risk of donor site morbidity and hides scarring.
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Kim YH, Shin HJ, Ju W, Kim SC. Prevention of lymphocele by using gelatin-thrombin matrix as a tissue sealant after pelvic lymphadenectomy in patients with gynecologic cancers: a prospective randomized controlled study. J Gynecol Oncol 2017; 28:e37. [PMID: 28382800 PMCID: PMC5391396 DOI: 10.3802/jgo.2017.28.e37] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 01/22/2017] [Accepted: 02/08/2017] [Indexed: 12/24/2022] Open
Abstract
Objective This prospective randomized controlled pilot study aimed to find whether gelatin-thrombin matrix used as a tissue sealant (FloSeal) can prevent the occurrence of pelvic lymphocele in patients with gynecologic cancer who has undergone pelvic lymphadenectomy. Methods Each patient, who undergo a laparotomic pelvic lymph node dissection on both sides, was randomly assigned for FloSeal application on 1 side of the pelvis. The other side of the pelvis without any product application being the control side. The amount of lymph drainage at each side of the pelvis was measured for 3 days, and computed tomography scans were obtained 7 days and 6 months after surgery for detection of pelvic lymphocele. Results Among 37 cases, the median amount of lymph drainage was significantly decreased in the hemi-pelvis treated with FloSeal compared to the control hemi-pelvis (p=0.025). The occurrence of lymphocele was considerably reduced in treated hemi-pelvis (8/37, 21.6%) compared with control hemi-pelvis (12/37, 32.4%) after 7 post-operative days (p=0.219), and more decreased in the treated hemi-pelvis (5/37, 13.5%) compared with control hemi-pelvis (9/37, 24.3%) after postoperative 6 months (p=0.344). Conclusion The application of FloSeal as a tissue sealant in lymph nodes resected tissues can reduce the incidence of pelvic lymphocele in gynecologic cancer patients. A large randomized controlled study could confirm these preliminary results.
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Affiliation(s)
- Yun Hwan Kim
- Department of Obstetrics and Gynecology, Ewha Womans University School of Medicine, Seoul, Korea.
| | - Hyun Joo Shin
- Department of Obstetrics and Gynecology, Ewha Womans University School of Medicine, Seoul, Korea
| | - Woong Ju
- Department of Obstetrics and Gynecology, Ewha Womans University School of Medicine, Seoul, Korea
| | - Seung Cheol Kim
- Department of Obstetrics and Gynecology, Ewha Womans University School of Medicine, Seoul, Korea
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Comparison of lymphedema incidence between 2 lymphadenectomy techniques in patients with uterine cancer undergoing robotic staging. Int J Gynecol Cancer 2015; 25:160-5. [PMID: 25386859 DOI: 10.1097/igc.0000000000000308] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE This study aimed to compare the incidence of lower extremity lymphedema in patients with uterine cancer after robotic staging using the following 2 methods: standard and selective pelvic lymphadenectomy. MATERIALS AND METHODS Three hundred forty-four consecutive patients who presented with endometrial cancer from March 2007 to October 2012 underwent robotic staging. Surgeon A performed standard pelvic lymphadenectomy and surgeon B performed selective lymphadenectomy. Selective pelvic lymphadenectomy spared the lateral chain of the external iliac lymph nodes (LNs). The incidence of lymphedema and staging adequacy between the 2 groups were analyzed. RESULTS Standard pelvic lymphadenectomy was performed in 238/344 (69.2%) patients and selective pelvic lymphadenectomy was performed in 106/344 (30.8%) patients. Conversion to laparotomy occurred in 2/344 cases (0.6%). Mean age for 344 patients was 63.6 (10) years and body mass index was 34.8 (10.1) kg/m(2). The mean operative time was 162.3 (54.6) minutes. Postoperative hospitalization was 1.62 (1.93) days. Histology included 80.8% endometrioid adenocarcinomas and 19.2% clear cell, serous, and carcinosarcomas. Mean pelvic LN counts for the standard and selective pelvic lymphadenectomy groups were 16 (8.6) and 15.5 (7.1), respectively (P = 0.31). Mean numbers of para-aortic LNs retrieved for the standard and selective lymphadenectomy groups were 3.1 (4.1) and 4.9 (4.5), respectively (P < 0.01).Median follow-up was 29.3 months (interquartile range, 15.6-43.1 months). The difference in the incidence of lower extremity lymphedema was statistically significant: 4.6% (11/238 patients) in the standard lymphadenectomy group versus 0.9% (1/106 patients) in the selective lymphadenectomy group (P = 0.03). CONCLUSIONS When compared to the standard technique, selective pelvic lymphadenectomy with sparing of the lateral chain of the external iliac LNs is adequate and results in a lower incidence of lower extremity lymphedema.
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Zikan M, Fischerova D, Pinkavova I, Slama J, Weinberger V, Dusek L, Cibula D. A prospective study examining the incidence of asymptomatic and symptomatic lymphoceles following lymphadenectomy in patients with gynecological cancer. Gynecol Oncol 2015; 137:291-8. [DOI: 10.1016/j.ygyno.2015.02.016] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Accepted: 02/16/2015] [Indexed: 11/25/2022]
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Bailey AP, Schutt AK, Pastore LM, Stovall DW. Pelvic pedicled omental flaps and autologous free omental grafts in a rabbit model. FERTILITY RESEARCH AND PRACTICE 2015; 1:3. [PMID: 28620508 PMCID: PMC5415197 DOI: 10.1186/2054-7099-1-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 06/13/2014] [Indexed: 12/03/2022]
Abstract
BACKGROUND There is a need to identify an inexpensive, effective method to prevent postoperative adhesion formation. The objective of this study was to create a novel model for studying omentum as a pelvic adhesion barrier. Randomized, prospective, controlled surgical intervention with serial follow-up in 16 female rabbits at a University-based Center for Comparative Medicine. Interventions included bilateral hysterotomy incision and repair. The left hysterotomy was randomized into coverage with an omental flap or graft; the right hysterotomy remained uncovered. Adhesions were scored via laparoscopy on postoperative days 2, 4, 8, and 12; postmortem evaluation and scoring took place on postoperative day 16. Statistical tests consisted of Kappa tests of agreement between adhesion scorers and Kruskal-Wallis nonparametric tests for the comparison of adhesion scores by intervention arm and by uterine horn. RESULTS All omental flaps and grafts survived. The only significant difference in mean adhesion scores was seen in non-hysterotomy-associated adhesions, where grafts had a lower score than flaps (p = 0.03). CONCLUSIONS Survival of all omental flaps and grafts demonstrates that this is a practical model for studying omentum as a pelvic adhesion barrier. Determining the efficacy of omentum as a pelvic adhesion barrier will require further investigation.
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Affiliation(s)
- Amelia P Bailey
- Department of Obstetrics and Gynecology, 75 Francis Street, Boston, MA 02115 USA
- Division of Reproductive Endocrinology and Infertility, University of Virginia, 1215 Lee Street, Charlottesville, VA 22903 USA
| | - Amy K Schutt
- Division of Reproductive Endocrinology and Infertility, University of Virginia, 1215 Lee Street, Charlottesville, VA 22903 USA
| | - Lisa M Pastore
- Division of Reproductive Endocrinology and Infertility, University of Virginia, 1215 Lee Street, Charlottesville, VA 22903 USA
| | - Dale W Stovall
- Division of Reproductive Endocrinology and Infertility, University of Virginia, 1215 Lee Street, Charlottesville, VA 22903 USA
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Shaitelman SF, Cromwell KD, Rasmussen JC, Stout NL, Armer JM, Lasinski BB, Cormier JN. Recent progress in the treatment and prevention of cancer-related lymphedema. CA Cancer J Clin 2015; 65:55-81. [PMID: 25410402 PMCID: PMC4808814 DOI: 10.3322/caac.21253] [Citation(s) in RCA: 146] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
This article provides an overview of the recent developments in the diagnosis, treatment, and prevention of cancer-related lymphedema. Lymphedema incidence by tumor site is evaluated. Measurement techniques and trends in patient education and treatment are also summarized to include current trends in therapeutic and surgical treatment options as well as longer-term management. Finally, an overview of the policies related to insurance coverage and reimbursement will give the clinician an overview of important trends in the diagnosis, treatment, and management of cancer-related lymphedema.
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Köhler C, Kyeyamwa S, Marnitz S, Tsunoda A, Vercelino F, Schneider A, Favero G. Prevention of lymphoceles using FloSeal and CoSeal after laparoscopic lymphadenectomy in patients with gynecologic malignancies. J Minim Invasive Gynecol 2014; 22:451-5. [PMID: 25499774 DOI: 10.1016/j.jmig.2014.12.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Revised: 12/03/2014] [Accepted: 12/04/2014] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Pelvic ± para-aortic lymphadenectomy (LAE) is an essential element of staging and treatment of different gynecologic malignancies. However, LAE can induce asymptomatic and symptomatic pelvic lymphoceles (LCs) in a considerable percentage of patients. Therapy of symptomatic LCs may cause additional morbidity. The best strategy to reduce the rate of LCs has not established yet. MATERIALS AND METHODS Between January 2011 and May 2012, transperitoneal laparoscopic pelvic ± para-aortic LAE was performed at the Department of Gynecology at Charité University Hospital Berlin in 238 patients with cervical, endometrial, ovarian, or groin-positive vulvar cancer. The application of FloSeal (Baxter, Deerfield, IL) and CoSeal (Baxter) was used in 25 patients (group A) as an alternative to routine pelvic drainage after LAE. A case-control comparison was performed on 25 patients (group B) with bilateral drainage after complete LAE. The primary objective of this pilot study was to evaluate the feasibility and safety of the method. As a secondary objective, we evaluated the incidence of LCs and symptomatic LCs in both groups. The detection of LCs was performed during oncologic follow-up by sonography, computed tomographic imaging, or magnetic resonance imaging. MEASUREMENTS AND MAIN RESULTS Pelvic (n = 50) or pelvic + para-aortic (n = 42) LAE was performed in 44 patients with cervical, 2 with endometrial, 1 with ovarian, and 2 with groin-positive vulvar cancer, respectively. In group B (n = 25), systematic bilateral pelvic drainage was placed after finishing LAE, whereas in group A (n = 25) LAE areas were sealed with 5 mL FloSeal on each side and sprayed with CoSeal afterward without placing drains. In 14 of 50 patients (28%), LCs were detected. In a subgroup of patients with cervical cancer (88% of the cohort), symptomatic LCs occurred in 11% in group A and 18% in group B. Operative revision of symptomatic LCs was necessary in 5% and 18% in groups A and B, respectively (p = .66). Mean Hospital stay was significant shorter in group A (6 days) versus B (8 days) (p = .027). CONCLUSION The results of this case-controlled pilot study indicate that the application of FloSeal and CoSeal after transperitoneal LAE is feasible and safe, may reduce hospital stay, and may potentially decrease the rate of symptomatic LCs in patients with gynecologic malignancies.
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Affiliation(s)
- Christhardt Köhler
- Department of Operative and Oncologic Gynecology, Asklepios Clinic, Hamburg, Germany
| | - Sarah Kyeyamwa
- Department of Gynecology, Charité Universitt of Gynec, Berlin, Germany
| | - Simone Marnitz
- Department of Radiooncology, Charité Universitt of Radio, Berlin, Germany
| | - Audrey Tsunoda
- Department of Gynecologic Oncology, Cancer Centre Barretos, Barretos, Brazil
| | | | - Achim Schneider
- Institute for Cytologie and Dyplasia, Füytologie and Dyp, Berlin, Germany
| | - Giovanni Favero
- Department of Operative and Oncologic Gynecology, Asklepios Clinic, Hamburg, Germany.
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Tsuda N, Ushijima K, Kawano K, Takemoto S, Nishio S, Sonoda G, Kamura T. Prevention of lymphocele development in gynecologic cancers by the electrothermal bipolar vessel sealing device. J Gynecol Oncol 2014; 25:229-35. [PMID: 25045436 PMCID: PMC4102742 DOI: 10.3802/jgo.2014.25.3.229] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 01/27/2014] [Accepted: 02/26/2014] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE A number of new techniques have been developed to prevent lymphocele formation after pelvic lymphadenectomy in gynecologic cancers. We assessed whether the electrothermal bipolar vessel sealing device (EBVSD) could decrease the incidence of postoperative lymphocele secondary to pelvic lymphadenectomy. METHODS A total of 321 patients with gynecologic cancer underwent pelvic lymphadenectomy from 2005 to 2011. Pelvic lymphadenectomy without EBVSD was performed in 134 patients, and pelvic lymphadenectomy with EBVSD was performed in 187 patients. We retrospectively compared the incidence of lymphocele and symptoms between both groups. RESULTS Four to 8 weeks after operation, 108 cases of lymphocele (34%) were detected by computed tomography scan examination. The incidence of lymphocele after pelvic lymphadenectomy was 56% (75/134) in the tie ligation group, and 18% (33/187) in the EBVSD group. We found a statistically significant difference in the incidence of lymphocele between both groups (p<0.01). To detect the independent risk factor for lymphocele development, we performed multivariate analysis with logistic regression for three variables (device, number of dissected lymph nodes, and operation time). Among these variables, we found a significant difference (p<0.001) for only one device. CONCLUSION Use of the EBVSD during gynecological cancer operation is useful for preventing the development of lymphocele secondary to pelvic lymphadenectomy.
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Affiliation(s)
- Naotake Tsuda
- Department of Obstetrics and Gynecology, Kurume University School of Medicine, Kurume, Japan
| | - Kimio Ushijima
- Department of Obstetrics and Gynecology, Kurume University School of Medicine, Kurume, Japan
| | - Kouichiro Kawano
- Department of Obstetrics and Gynecology, Kurume University School of Medicine, Kurume, Japan
| | - Shuji Takemoto
- Department of Obstetrics and Gynecology, Kurume University School of Medicine, Kurume, Japan
| | - Shin Nishio
- Department of Obstetrics and Gynecology, Kurume University School of Medicine, Kurume, Japan
| | - Gounosuke Sonoda
- Department of Obstetrics and Gynecology, Kurume University School of Medicine, Kurume, Japan
| | - Toshiharu Kamura
- Department of Obstetrics and Gynecology, Kurume University School of Medicine, Kurume, Japan
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Bifulco G, Giampaolino P, Morra I, Tommaselli GA, Tarsitano F, Chiacchio G, Nappi C, Di Carlo C. Synthetic cyanoacrylic glue in the prevention of post-operative lymphocele after pelvic lymphadenectomy in patients with uterine malignancies: A prospective, single-blind, preliminary study. Gynecol Oncol 2014; 134:556-60. [PMID: 24967744 DOI: 10.1016/j.ygyno.2014.06.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 06/11/2014] [Accepted: 06/15/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Lymphoceles are among the most common post-operative complications of pelvic lymphadenectomy, with a reported incidence of 1% to 29% in gynecology oncology. Several studies evaluated the effectiveness of biological glues on reducing lymphoceles, but no data on gynecological patients are available. We evaluated the effectiveness of cyanoacrylic glues (n-butyl cyanoacrylate) (Glubran 2 - GEM s.r.l., Italy) in preventing lymphocele on 30 patients who underwent pelvic lymphadenectomy for endometrial or cervical cancer. METHODS Single-blind prospective randomized study. Patients were divided into 2 groups: pelvic lymphadenectomy plus n-butyl cyanoacrylate (treatment group: 44 patients) and pelvic lymphadenectomy without n-butyl cyanoacrylate (control group: 44 patients). Primary endpoint was incidence of pelvic lymphocele in the two groups 30 days after surgery, and evaluated with pelvic ultrasound and RMI examination. Secondary endpoints evaluated drainage volume of lymphorrhea 36, 48, 72 and 96 h after surgery. RESULTS 15% in the treatment group and 36.6% in the control group had lymphocele 1month after the procedure (p<0.03; RR 0.4 [95% CI 0.152-0.999]). Concerning the secondary outcome in group A the amount of lymphorrhea presented a constant significant decrease during evaluation; on the contrary, in group B, after an initial decrease at 48 h, the amount of lymphorrhea remained unchanged; at all considered times the amount of lymphorrhea resulted significantly greater in controls. CONCLUSION Intraoperative application of n-butyl cyanoacrylate seems to reduce lymph production after pelvic lymphadenectomy, providing a useful additional treatment option for reducing drainage volume and preventing lymphocele development after pelvic lymphadenectomy.
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Affiliation(s)
- G Bifulco
- Department of Gynaecology and Obstetrics, and Pathophysiology of Human Reproduction, University of Naples "Federico II", Via Pansini 5, 80131 Naples, Italy
| | - P Giampaolino
- Department of Gynaecology and Obstetrics, and Pathophysiology of Human Reproduction, University of Naples "Federico II", Via Pansini 5, 80131 Naples, Italy.
| | - I Morra
- Department of Gynaecology and Obstetrics, and Pathophysiology of Human Reproduction, University of Naples "Federico II", Via Pansini 5, 80131 Naples, Italy
| | - G A Tommaselli
- Department of Gynaecology and Obstetrics, and Pathophysiology of Human Reproduction, University of Naples "Federico II", Via Pansini 5, 80131 Naples, Italy
| | - F Tarsitano
- Department of Gynaecology and Obstetrics, and Pathophysiology of Human Reproduction, University of Naples "Federico II", Via Pansini 5, 80131 Naples, Italy
| | - G Chiacchio
- Department of Gynaecology and Obstetrics, and Pathophysiology of Human Reproduction, University of Naples "Federico II", Via Pansini 5, 80131 Naples, Italy
| | - C Nappi
- Department of Gynaecology and Obstetrics, and Pathophysiology of Human Reproduction, University of Naples "Federico II", Via Pansini 5, 80131 Naples, Italy
| | - C Di Carlo
- Department of Gynaecology and Obstetrics, and Pathophysiology of Human Reproduction, University of Naples "Federico II", Via Pansini 5, 80131 Naples, Italy
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Weinberger V, Cibula D, Zikan M. Lymphocele: prevalence and management in gynecological malignancies. Expert Rev Anticancer Ther 2014; 14:307-17. [DOI: 10.1586/14737140.2014.866043] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kondo E, Tabata T, Shiozaki T, Motohashi T, Tanida K, Okugawa T, Ikeda T. Large or persistent lymphocyst increases the risk of lymphedema, lymphangitis, and deep vein thrombosis after retroperitoneal lymphadenectomy for gynecologic malignancy. Arch Gynecol Obstet 2013; 288:587-93. [DOI: 10.1007/s00404-013-2769-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2012] [Accepted: 02/14/2013] [Indexed: 10/27/2022]
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Achouri A, Huchon C, Bats AS, Bensaid C, Nos C, Lécuru F. Complications of lymphadenectomy for gynecologic cancer. Eur J Surg Oncol 2012; 39:81-6. [PMID: 23117018 DOI: 10.1016/j.ejso.2012.10.011] [Citation(s) in RCA: 156] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 10/02/2012] [Accepted: 10/12/2012] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Symptomatic postoperative lymphocysts (SPOLs) and lower-limb lymphedema (LLL) are probably underestimated complications of lymphadenectomy for gynecologic malignancies. Here, our objective was to evaluate the incidence and risk factors of SPOLs and LLL after pelvic and/or aortocaval lymphadenectomy for gynecologic malignancies. METHODS Single-center retrospective study of consecutive patients who underwent pelvic and/or aortocaval lymphadenectomy for ovarian cancer, endometrial cancer, or cervical cancer between January 2007 and November 2008. The incidences of SPOL and LLL were computed with their 95% confidence intervals (95%CIs). Multivariate logistic regression was performed to identify independent risk factors for SPOL and LLL. RESULTS We identified 88 patients including 36 with ovarian cancer, 35 with endometrial cancer, and 17 with cervical cancer. The overall incidence of SPOL was 34.5% (95%CI, 25-45) and that of LLL was 11.4% (95% confidence interval [95%CI], 5-18). Endometrial cancer was independently associated with a lower risk of SPOL (adjusted odds ratio [aOR], 0.09; 95%CI, 0.02-0.44) and one or more positive pelvic nodes with a higher risk of SPOL (aOR, 4.4; 95%CI, 1.2-16.3). Multivariate logistic regression failed to identify factors significantly associated with LLL. CONCLUSION Complications of lymphadenectomy for gynecologic malignancies are common. This finding supports a more restrictive use of lymphadenectomy or the use of less invasive techniques such as sentinel node biopsy.
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Affiliation(s)
- A Achouri
- Service de Chirurgie Cancérologique Gynécologique et du Sein, Hôpital Européen Georges Pompidou, AP-HP, Paris, France.
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Achouri A, Huchon C, Bats AS, Bensaïd C, Nos C, Lécuru F. Postoperative lymphocysts after lymphadenectomy for gynaecological malignancies: preventive techniques and prospects. Eur J Obstet Gynecol Reprod Biol 2012; 161:125-9. [DOI: 10.1016/j.ejogrb.2011.12.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Revised: 11/15/2011] [Accepted: 12/20/2011] [Indexed: 11/24/2022]
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Ghezzi F, Uccella S, Cromi A, Bogani G, Robba C, Serati M, Bolis P. Lymphoceles, lymphorrhea, and lymphedema after laparoscopic and open endometrial cancer staging. Ann Surg Oncol 2012; 19:259-267. [PMID: 21695563 DOI: 10.1245/s10434-011-1854-5] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2011] [Indexed: 09/19/2023]
Abstract
PURPOSE To evaluate the incidence of lymphoceles, lymphorrhea, and lymphedema after systematic pelvic lymphadenectomy in patients who underwent laparoscopic or open abdominal staging for endometrial cancer. METHODS A total of 138 consecutive women who underwent systematic laparoscopic pelvic lymphadenectomy for endometrial cancer staging were compared to 123 historical control subjects staged via an open approach. Postoperative screening for lymphadenectomy-related complications by ultrasound was consistently performed. RESULTS The incidence of perioperative complications was lower in cases than in control subjects. Overall, lymphoceles were diagnosed in 19 (15.4%) and 2 (1.4%) patients who had open and laparoscopic staging, respectively (odds ratio 12.42; 95% confidence interval 2.82-54.55; P < 0.0001). Symptomatic lymphoceles were more frequent after open staging than after laparoscopy (P = 0.028). Lymphorrhea occurred in 1 and 4 patients after laparoscopic and open surgery (P = 0.19). No difference in the incidence of lymphedema was observed. CONCLUSIONS Our findings suggest that laparoscopic endometrial cancer staging is associated with a lower occurrence of both asymptomatic and symptomatic lymphoceles compared to open surgery.
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Affiliation(s)
- Fabio Ghezzi
- Department of Obstetrics and Gynecology, University of Insubria, Del Ponte Hospital, Varese, Italy.
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[Prevention of lymphoceles and gynaecologic cancers]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2011; 39:698-703. [PMID: 22104967 DOI: 10.1016/j.gyobfe.2011.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2011] [Accepted: 09/20/2011] [Indexed: 02/06/2023]
Abstract
Lymphoceles are the most frequent complications following systematic lymphadenectomy in gynaecologic cancers. Some of them may have clinical significance with high morbidity. Through a review of literature, we describe surgical methods (way of surgery, lymphadenectomy type, sentinel lymph node, peritonization, drainages, lymphostasis, surgical patch) and medical methods (somatostatin analogs and nutrition treatment) which could prevent lymphoceles formation after pelvic and lumboaortic lymphadenectomy.
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Tinelli A, Giorda G, Manca C, Pellegrino M, Prudenzano R, Guido M, Dell'edera D, Malvasi A. Prevention of lymphocele in female pelvic lymphadenectomy by a collagen patch coated with the human coagulation factors: A pilot study. J Surg Oncol 2011; 105:835-40. [DOI: 10.1002/jso.22110] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2011] [Accepted: 09/10/2011] [Indexed: 11/07/2022]
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Kashiwagi S, Hosono K, Suzuki T, Takeda A, Uchinuma E, Majima M. Role of COX-2 in lymphangiogenesis and restoration of lymphatic flow in secondary lymphedema. J Transl Med 2011; 91:1314-25. [PMID: 21577211 DOI: 10.1038/labinvest.2011.84] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The pathophysiology of secondary lymphedema remains poorly understood. To clarify the roles of cyclooxygenase (COX)-2 in enhancement of lymphangiogenesis during secondary lymphedema, we tested a mouse tail model and evaluated the recurrence of lymph flow. To induce lymphedema, a circumferential incision was made in the tail of anesthetized mice to sever the dermal lymphatic vessels. The maximum diameters of the tails were measured weekly. We found that the diameters of the tails around the wounds were markedly increased after surgery, and reached maximum size 2 weeks after wounding in mice without a COX-2 inhibitor, celecoxib (Celecoxib-). Expression of COX-2 in wound granulation tissues was markedly increased 1 week after surgery compared with unwounded naive control mice. In Celecoxib-, recurrence of lymphatic flow in the wound granulation tissues was detected 3 weeks after surgical treatment. In contrast, lymphatic flow was markedly suppressed in mice treated with celecoxib (Celecoxib+). Newly formed lymphatic structures were identified in the granulation tissues formed at wounded lesions in Celecoxib-, whereas those were markedly suppressed in Celecoxib+. Interstitial tissue pressures in the distal areas of the tail wounds were markedly increased in Celecoxib+ with reduced expression of vascular endothelial cell growth factor (VEGF)-C. F4/80-positive cells were accumulated to the wound granulation tissues in Celecoxib-, and the accumulation of these cells was suppressed in Celecoxib+. Prostaglandin E(2) (PGE(2)) upregulated the expressions of VEGF-A and VEGF-C in cultured macrophages, but not human lymphatic microvascular endothelial cells. The present study therefore suggests that lymphangiogenesis, together with recurrence of lymph flow after surgical induction of lymphedema, is upregulated by COX-2 possibly via generation of PGs.
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Affiliation(s)
- Shinya Kashiwagi
- Department of Pharmacology, Kitasato University School of Medicine, Kanagawa, Japan
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Cormier JN, Rourke L, Crosby M, Chang D, Armer J. The surgical treatment of lymphedema: a systematic review of the contemporary literature (2004-2010). Ann Surg Oncol 2011; 19:642-51. [PMID: 21863361 DOI: 10.1245/s10434-011-2017-4] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2011] [Indexed: 12/24/2022]
Abstract
PURPOSE A systematic review of the literature was performed to examine contemporary peer-reviewed literature (2004-2010) evaluating the surgical treatment of lymphedema. METHODS A comprehensive search of 11 major medical indices was performed. Selected articles were sorted to identify those related to the surgical treatment of lymphedema. Extracted data included the number of patients, specific surgical procedure performed, length of follow-up, criteria for defining lymphedema, measurement methods, volume or circumference reduction, and reported complications. RESULTS A total of 20 studies met inclusion criteria; procedures were categorized as excisional procedures (n = 8), lymphatic reconstruction (n = 8), and tissue transfer (n = 4). The reported incidence of volume reduction of lymphedema in these studies varied from 118% reduction to a 13% increase over the follow-up intervals ranging from 6 months to 15 years. The largest reported reductions were noted after excisional procedures (91.1%), lymphatic reconstruction (54.9%), and tissue transfer procedures (47.6%). Procedure complications were rarely reported. CONCLUSIONS A number of surgical approaches have demonstrated beneficial effects for select patients with lymphedema. Most of these reports, however, are based on small numbers of patients, use nonstandardized or inconsistent measurement techniques, and lack long-term follow-up. The proposed benefits of any surgical approach should be evaluated in the context of the potential morbidity to the individual patient and the availability of surgical expertise. In addition, although these surgical techniques have shown promising results, nearly all note that the procedures do not obviate the need for continued use of conventional therapies, including compression, for long-term maintenance.
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Affiliation(s)
- Janice N Cormier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Hareyama H, Ito K, Hada K, Uchida A, Hayakashi Y, Hirayama E, Oikawa M, Okuyama K. Reduction/prevention of lower extremity lymphedema after pelvic and para-aortic lymphadenectomy for patients with gynecologic malignancies. Ann Surg Oncol 2011; 19:268-73. [PMID: 21717243 DOI: 10.1245/s10434-011-1863-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Lower extremity lymphedema (LEL) is a serious complication caused by lymphadenectomy in patients with gynecologic malignancies. In this study, we evaluated the effect of preserving the circumflex iliac lymph nodes (CILNs), i.e., the most caudal external iliac lymph nodes, for the prevention and reduction of LEL by comparing two groups of patients, one in which CILN were removed and the other in which CILNs were preserved. METHODS We retrospectively reviewed 329 patients with gynecologic malignancies who had undergone abdominal complete systematic pelvic and para-aortic lymphadenectomy. The patients were divided into nonpreserved (n = 189) and preserved (n = 140) groups, depending on whether CILNs were removed. Primary outcome measures included the incidence and severity of LEL. RESULTS The incidence of LEL was significantly lower in the preserved group than in the nonpreserved group (P < 0.0001). The frequency of LEL was also significantly lower in the preserved group than in the nonpreserved group regardless of the range of pelvic and para-aortic lymphadenectomy (P < 0.0001). LEL in the overwhelming majority of cases in the preserved group was mild, and no patients experienced severe LEL. Further, the incidence of cellulitis was 0% in the preserved group, while it was 12.7% in the nonpreserved group (P < 0.0001). Lymphoscintigraphy revealed collateral pathways from the preserved CILN along the iliac and large abdominal vessels. CONCLUSIONS This method of lymph node preservation is a simple and extremely effective approach for preventing/reducing LEL after pelvic and para-aortic lymphadenectomy for patients with gynecologic malignancies.
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Affiliation(s)
- Hitoshi Hareyama
- Department of Obstetrics and Gynecology, Sapporo City General Hospital, Sapporo, Japan.
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Cormier JN, Askew RL, Mungovan KS, Xing Y, Ross MI, Armer JM. Lymphedema beyond breast cancer: a systematic review and meta-analysis of cancer-related secondary lymphedema. Cancer 2011; 116:5138-49. [PMID: 20665892 DOI: 10.1002/cncr.25458] [Citation(s) in RCA: 315] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Secondary lymphedema is a debilitating, chronic, progressive condition that commonly occurs after the treatment of breast cancer. The purpose of the current study was to perform a systematic review and meta-analysis of the oncology-related literature excluding breast cancer to derive estimates of lymphedema incidence and to identify potential risk factors among various malignancies. METHODS The authors systematically reviewed 3 major medical indices (MEDLINE, Cochrane Library databases, and Scopus) to identify studies (1972-2008) that included a prospective assessment of lymphedema after cancer treatment. Studies were categorized according to malignancy, and data included treatment, complications, lymphedema measurement criteria, lymphedema incidence, and follow-up interval. A quality assessment of individual studies was performed using established criteria for systematic reviews. Bayesian meta-analytic techniques were applied to derive summary estimates when sufficient data were available. RESULTS A total of 47 studies (7779 cancer survivors) met inclusion criteria: melanoma (n = 15), gynecologic malignancies (n = 22), genitourinary cancers (n = 8), head/neck cancers (n = 1), and sarcomas (n = 1). The overall incidence of lymphedema was 15.5% and varied by malignancy (P < .001): melanoma, 16% (upper extremity, 5%; lower extremity, 28%); gynecologic, 20%; genitourinary, 10%; head/neck, 4%; and sarcoma, 30%. Increased lymphedema risk was also noted for patients undergoing pelvic dissections (22%) and radiation therapy (31%). Objective measurement methods and longer follow-up were both associated with increased lymphedema incidence. CONCLUSIONS Lymphedema is a common condition affecting cancer survivors with various malignancies. The incidence of lymphedema is related to the type and extent of treatment, anatomic location, heterogeneity of assessment methods, and length of follow-up.
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Affiliation(s)
- Janice N Cormier
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA.
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Park NY, Seong WJ, Chong GO, Hong DG, Cho YL, Park IS, Lee YS. The effect of nonperitonization and laparoscopic lymphadenectomy for minimizing the incidence of lymphocyst formation after radical hysterectomy for cervical cancer. Int J Gynecol Cancer 2010; 20:443-8. [PMID: 20375812 DOI: 10.1111/igc.0b013e3181d1895f] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To determine the clinical effect of nonperitonization and laparoscopic lymphadenectomy using bipolar electrocautery after radical hysterectomy for cervical cancer compared with peritonization and open lymphadenectomy using monopolar electrocautery. MATERIALS AND METHODS This was a retrospective study of 180 patients who underwent a radical hysterectomy and pelvic lymph node dissection (PLND) for cervical cancer from August 1998 to August 2007. The patients were composed of the Peritonization + Laparotomy group (group A; n = 98, 196 PLND) and the Nonperitonization + Laparoscopy group (group B; n = 82, 164 PLND). Group B left the peritoneum in front of the PLND open. Two closed-suction drains were placed at each side of the PLND. RESULTS Group B statistically showed a lesser total amount of lymphatic drainage (P = 0.001), shorter duration of inserted drains (P < 0.001), and shorter length of hospital stay (P < 0.001), compared with group A. The formation of lymphocysts occurred in 30 patients (41 lymphocysts) of group A and 5 patients (5 lymphocysts) of group B. Lymphocyst formation of group B had a statistically lower incidence than that of group A (P < 0.001). Lymphocyst formation was associated with an increase in the total amount of lymphatic drainage in group A (P = 0.090) and group B (P = 0.041) and a pathologic type of adenocarcinoma in group B (P = 0.016). Surgical experiences were not correlated with lymphocyst formation. CONCLUSIONS The omission of peritonization and laparoscopic lymphadenectomy using bipolar electrocautery in early-stage cervical cancer were more effective than peritonization and open lymphadenectomy using monopolar electrocautery in minimizing the incidence of lymphocyst formation.
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Affiliation(s)
- Nae Yoon Park
- Department of Obstetrics and Gynecology, School of Medicine, Kyungpook National University Hospital, Daegu, Korea
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Abbas S, Seitz M. Systematic review and meta-analysis of the used surgical techniques to reduce leg lymphedema following radical inguinal nodes dissection. Surg Oncol 2009; 20:88-96. [PMID: 20005090 DOI: 10.1016/j.suronc.2009.11.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2009] [Revised: 11/14/2009] [Accepted: 11/16/2009] [Indexed: 11/29/2022]
Abstract
BACKGROUND Inguinal nodes dissection is associated with high rates of morbidity, lymphedema in particular is a chronic disabling condition which is a common complication following this operation. Prevention or minimization of this condition is an important aim when considering this procedure. Many technical modifications are suggested for this purpose. This systematic review aims at assessing the efficacy of the available strategies to reduce the risk and severity of leg lymphedema. METHODS For this review, MEDLINE and EMBASE were searched to identify studies that reported surgical strategies designed to reduce complications of groin dissection and in particular leg lymphedema. Studies that reported outcome of long saphenous vein sparing, fascia preserving dissection, microvascular surgery, sartorius transposition and omental pedicle flap were located. Data were collected using predefined inclusion and exclusion criteria. A combined odds ratio was calculated combining studies suitable for meta-analysis using the random effect model. RESULTS The search result defined few studies that reported results of saphenous vein sparing technique; some of those studies were found suitable for meta-analysis based on the Newcastle-Ottawa scale for non-randomized studies. The meta-analysis showed significant reduction of lymphedema (odds ratio 0.24, 95% CI 0.11-0.53) and other complications of inguinal node dissection. There were no randomized studies to address this problem; there are also isolated studies that reported benefits of other techniques but none of them was suitable for meta-analysis. CONCLUSION Meta-analysis of the reported studies on sparing the long saphenous vein in inguinal nodes dissection suggests a reduced rate of lymphedema and other postoperative complications. Other methods that may be beneficial are fascia preserving dissection, pedicled omental flap and microsurgery; however sartorius transposition has not been shown to reduce the rate of complications. Randomized controlled trials are needed to prove the benefits of various technical modifications.
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Affiliation(s)
- Saleh Abbas
- Hunter and New England Health Area, Manning Hospital, 26 YORK Street, Taree, NSW 2430, Australia.
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Sawan S, Mugnai R, de Barros Lopes A, Hughes A, Edmondson RJ. Lower-Limb Lymphedema and Vulval Cancer: Feasibility of Prophylactic Compression Garments and Validation of Leg Volume Measurement. Int J Gynecol Cancer 2009; 19:1649-54. [DOI: 10.1111/igc.0b013e3181a8446a] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objectives:Leg lymphedema remains a significant health problem after treatment of vulval cancer. This pilot study explored the feasibility of conducting a larger trial to investigate whether the early use of compression stockings is effective in preventing leg lymphedema.Methods:Fourteen patients undergoing inguinofemoral lymphadenectomy for vulval cancer were randomized to either best supportive care or best supportive care plus the use of graduated compression stockings for 6 months.Results:Six of 7 patients in the treatment group complied with the study protocol. The incidence of clinically significant lymphedema was not different between both groups; however, there was a greater increase in mean leg volume in the control group (953 vs 607 mL, P = 0.010). Furthermore, patients in the treatment group showed better performance as judged by leg symptoms (P = 0.031, at 3 months) and clinical examination (P = 0.039 at 4 weeks and P = 0.004 at 6 months). There was no difference in the incidence of groin wound dehiscence, infection, or lymphocyst formation. We detected no difference between both groups' scores when using a validated quality-of-life questionnaire. Intraobserver and interobserver variabilities of leg-volume measurement technique were investigated using the principles of repeatability and reproducibility statistics. Intraobserver variability was estimated at 270 mL, whereas interobserver variability was 1000 mL.Conclusions:The prophylactic use of stockings in this population is feasible, and further larger studies are justified to investigate its role in reducing the incidence of leg lymphedema. The design of these studies should take into account the observer-related variability in measuring leg volume or consider alternative methods.
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Bacha OM, Plante M, Kirschnick LS, Edelweiss MI. Evaluation of morbidity of suction drains after retroperitoneal lymphadenectomy in gynecological tumors: a systematic literature review. Int J Gynecol Cancer 2009; 19:202-7. [PMID: 19395994 DOI: 10.1111/igc.0b013e31819a1fbe] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION The prophylactic use of closed suction drains after retroperitoneal lymphadenectomy in the management of gynecologic tumors has been widely used to prevent collections of clots or lymph and to avoid infections and postoperative fistulas. The improvement of newer surgical techniques, the use of antibiotic prophylaxis, and the nonclosure of the peritoneum led to the need to reevaluate the use of drains. Retrospective, prospective, and randomized studies did not find differences in the postoperative morbidity between the use and nonuse of drains. Some studies even suggested worse morbidity with the use of drains. OBJECTIVES To assess the morbidity of the use of drains compared with no drains in a systematic literature review with aggregate effect measure (meta-analysis). MATERIALS AND METHODS Between 1966 and August 2007, 3 independent reviewers analyzed all studies that assessed the use of drains or no drains through a comprehensive literature search of the MEDLINE, EMBASE, and Cochrane Central Databases. Statistical analysis was carried out through the RevMan software. RESULTS Of the 285 studies initially reviewed, 11 were selected. Only 4 were considered adequate for group analysis, totaling 571 patients. When assessing outcomes altogether, namely, fever morbidity, symptomatic lymphocysts, deep vein thrombosis, pelvic infection, and fistulas, the relative risk was 1.76 (95% confidence interval, 1.04-3.01) and number necessary to harm was 12.2 referring to the use of drains. CONCLUSIONS The prophylactic use of continuous suction drains after retroperitoneal lymphadenectomy in the management of gynecologic tumors should be avoided.
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Tada H, Teramukai S, Fukushima M, Sasaki H. Risk factors for lower limb lymphedema after lymph node dissection in patients with ovarian and uterine carcinoma. BMC Cancer 2009; 9:47. [PMID: 19193243 PMCID: PMC2660366 DOI: 10.1186/1471-2407-9-47] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2008] [Accepted: 02/05/2009] [Indexed: 11/25/2022] Open
Abstract
Background Lymph node dissection has proven prognostic benefits for patients with ovarian or uterine carcinoma; however, one of the complications associated with this procedure is lymphedema. We aimed to identify the factors that are associated with the occurrence of lymphedema after lymph node dissection for the treatment of ovarian or uterine carcinoma. Methods A total of 694 patients with histologically confirmed ovarian (135 patients) or uterine cancer (258 with cervical cancer, 301 with endometrial cancer) who underwent lymph node dissection were studied retrospectively. Logistic regression analyses were used to identify the risk factors associated with occurrence of lymphedema. Results Among ovarian and uterine cancer patients who underwent pelvic lymph node dissection, post-operative radiotherapy (odds ratio: 1.79; 95% confidence interval: 1.20–2.67; p = 0.006) was statistically significantly associated with occurrence of lymphedema. Conclusion There was no relationship between any surgical procedure and occurrence of lymphedema among patients undergoing pelvic lymphadenectomy. Our findings are supported by a sound biological rationale because they suggest that limb lymphedema is caused by pelvic lymph node dissection.
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Affiliation(s)
- Harue Tada
- Department of Clinical Trial Design and Management, Translational Research Center, Kyoto University Hospital, Sakyo-ku, Kyoto, Japan.
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Tanaka T, Ohki N, Kojima A, Maeno Y, Miyahara Y, Sudo T, Takekida S, Yamaguchi S, Sasaki H, Nishimura R. Radiotherapy negates the effect of retroperitoneal nonclosure for prevention of lymphedema of the legs following pelvic lymphadenectomy for gynecological malignancies: an analysis from a questionnaire survey. Int J Gynecol Cancer 2007; 17:460-4. [PMID: 17316358 DOI: 10.1111/j.1525-1438.2007.00869.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Using patient questionnaires, we studied the long-term effect of leaving the peritoneum open on the incidence of lymphedema of the legs in patients following pelvic lymphadenectomy for gynecological malignancies. The patients were retrospectively assigned to one of two groups, depending on whether the retroperitoneum was closed or left open at surgery. Three years after surgery, we obtained valid questionnaire responses from 101 patients (43 cervical, 46 endometrial, and 12 ovarian cancers) in the closure group and 83 patients (34 cervical, 40 endometrial, and 9 ovarian cancers) in the nonclosure group. In patients' self-analysis, the overall incidence of lymphedema of the legs was significantly lower in the nonclosure group than in the closure group (25.3% and 50.5%, respectively; P < 0.01). The incidence of lymphedema of the legs was significantly increased by postoperative radiotherapy. Especially in the nonclosure group, the incidence of lymphedema was only 15.8% in patients who did not have radiotherapy, but it increased significantly (44.4%) (P < 0.05) when patients underwent radiotherapy. In conclusion, this questionnaire survey suggested that leaving the retroperitoneum open after lymphadenectomy is significantly effective in reducing the incidence of leg lymphedema, which impairs patients' quality of life more than expected by physicians.
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Affiliation(s)
- T Tanaka
- Department of Gynecology, Hyogo Medical Center for Adults, Akashi, Japan
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Takeishi M, Kojima M, Mori K, Kurihara K, Sasaki H. Primary Intrapelvic Lymphaticovenular Anastomosis Following Lymph Node Dissection. Ann Plast Surg 2006; 57:300-4. [PMID: 16929199 DOI: 10.1097/01.sap.0000222727.05869.04] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Lymphedema of lower extremities occurs following surgical resection of malignant tumors and intrapelvic lymph node dissection and is a long-term problem for patients. We performed primary intrapelvic lymphaticovenular anastomosis to prevent postoperative leg lymphedema. The procedures were conducted in 7 patients (aged 35-61 years) with cancer of the uterine body. After completion of hystero-oophorectomy and intrapelvic lymph node dissection, the afferent lymphatics entering internal and external iliac lymph nodes were end-to-end anastomosed with branches of the deep inferior epigastric veins. The time taken for constructing 4 anastomoses was 100 to 120 minutes. The follow-up period ranged from 10 to 18 months (mean, 14 months). All patients were discharged and are independent in daily living. Apart from mild leg lymphedema in 1 patient, no lymphedema was observed in other patients up to the last follow-up. This surgical modality is effective in preventing lymphedema in lower extremities after intrapelvic para-aortic lymph node dissection.
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Affiliation(s)
- Meisei Takeishi
- Department of Plastic and Reconstructive Surgery , Jikei University School of Medicine, Minatoku Tokyo, Japan.
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Lurie DM, Seguin B, Schneider PD, Verstraete FJ, Wisner ER. Contrast-assisted ultrasound for sentinel lymph node detection in spontaneously arising canine head and neck tumors. Invest Radiol 2006; 41:415-21. [PMID: 16523025 DOI: 10.1097/01.rli.0000201230.29925.95] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We sought to evaluate a minimally invasive contrast-assisted ultrasound (US) technique for sentinel lymph node (SLN) localization. METHODS Microbubble contrast medium was injected into peritumoral tissues in 10 dogs with spontaneous head or neck tumors. Regional lymph nodes (LNs) were imaged up to 20 minutes after contrast administration using power Doppler US. Comparative lymphoscintigraphy studies were performed in all dogs by peritumoral injection of 99mTc-sulfur colloid administered around the primary lesion. RESULTS US contrast enhancement of SLN revealed sentinel nodes and associated lymphatics in 8 of 10 dogs. In each instance in which contrast-enhanced LN was identified with US, a corresponding SLN was detected by lymphoscintigraphy. Multiple SLNs were present in 2 dogs. Regional lymph nodes were positive for metastasis in 1 dog and reactive in 9 dogs. CONCLUSIONS Contrast-assisted US is effective in localizing SLN. This technique could reduce or eliminate many of the limitations of current SLN detection procedures.
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Affiliation(s)
- David M Lurie
- Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California, Davis, 95616, USA
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Benoit L, Boichot C, Cheynel N, Arnould L, Chauffert B, Cuisenier J, Fraisse J. Preventing lymphedema and morbidity with an omentum flap after ilioinguinal lymph node dissection. Ann Surg Oncol 2005; 12:793-9. [PMID: 16132379 DOI: 10.1245/aso.2005.09.022] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2004] [Accepted: 04/04/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND Pedicled omentoplasty has been advocated to prevent the formation of lymphocysts and lymphedema after pelvic lymph node dissection, We evaluated the possible benefit of a pediculated omentoplasty placed in the groin for preventing complications after ilioinguinal lymph node dissection. METHODS In this pilot study, we report a series of four women and three men with inguinal metastatic lymph nodes. Each was treated with a pediculated omentoplasty after groin dissection. We examined complications such as lymphedema, lymphorrhea, wound breakdown, skin necrosis, and lymphocysts. RESULTS Only one wound breakdown with skin necrosis was observed, and it healed satisfactorily in 10 days without exposing the femoral vessels. No lymphocele or infectious complications occurred, even though no antibiotic prophylaxis was used. Midthigh circumference increase ranged from 1.5 to 7 cm in four cases but remained asymptomatic. Furthermore, lymphedema of the lower limb decreased in the three remaining patients, who previously had an enlargement of the thigh. No evidence of peritoneal carcinomatosis was noted during the 4-month follow-up. CONCLUSIONS Pedicled omentoplasty seemed to facilitate the absorption or transport of lymph fluids and resulted in less lymphedema in the lower limb even after radiotherapy. Pedicled omentoplasty reduces both short-term and long-term postoperative complications without affecting treatment outcome and could even be considered as a safe and effective therapy for lymphedema of the lower extremity.
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Affiliation(s)
- Laurent Benoit
- Service de Chirurgie Digestive, Thoracique, et Cancérologique, CHU du Bocage, B.P. 77908, 21079, Dijon Cedex, France.
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Abstract
Lymphoedema is a problem frequently encountered by professionals working in palliative care. This article reviews the evidence on the magnitude of the problem of lymphoedema in the general population and provides evidence on specific high risk groups within it. Prevalence is a good indicator of the burden of disease for chronic problems such as lymphoedema, as it indicates the numbers of patients who require care. Incidence is indicative of changes in the causes of lymphoedema and the success of any prevention programmes. Both are important means of assessing the current level of need and the potential for the changing needs in managing this condition. Problems exist in all studies in relation to precise definitions of lymphoedema, inconsistent measures to assess differential diagnosis and poorly defined populations. While there is some evidence of high rates in relation to breast cancer therapy, the total burden of lymphoedema in the general population is largely unknown.
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Affiliation(s)
- Anne F Williams
- Centre for Research and Implementation of Clinical Practice, Thames Valley University, London, UK
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Kim HY, Kim JW, Kim SH, Kim YT, Kim JH. An analysis of the risk factors and management of lymphocele after pelvic lymphadenectomy in patients with gynecologic malignancies. Cancer Res Treat 2004; 36:377-83. [PMID: 20368832 DOI: 10.4143/crt.2004.36.6.377] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2004] [Accepted: 12/06/2004] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES The incidence and risk factors of lymphocele development after pelvic lymphadenectomy were evaluated and its management investigated. MATERIALS AND METHODS This retrospective study was carried out on 264 patients who received a pelvic lymphadenectomy, between March 1999 and February 2003, due to gynecologic cancer. The patients were classified into two groups; the lymphocele (n=50) and non-lymphocele groups (n=214), as confirmed by ultrasonography, CT scan and MRI. Each group was compared by cancer type and stage, BMI, preoperative Hb, use of pre/postoperative chemotherapy or radiotherapy, number of resected pelvic lymph nodes and the volume of postoperative drainage from a Hemovac pelvic drain. RESULTS Of the 264 patients tested, 15 of 105 cervical cancer (14%), 22 of 115 ovarian cancer (19%) and 11 of 40 endometrial cancer patients (27%), a total of 50 patients (18%), developed lymphoceles. In the lymphocele group (n=50), 13 patients were diagnosed with complicated lymphocele. The BMI and number of resected pelvic lymph nodes were found to be higher in the lymphocele than in the non-lymphocele group (23.94+/-3.38 vs. 22.52+/-3.00, p=0.00 and 26.80+/-14.82 vs. 22.96+/-10.18, p=0.03, respectively), and showed statistical significance. The occurrence of lymphoceles was lower without postoperative radiotherapy (p=0.01). CONCLUSION Among the 264 patients, a total of 50 patients (18%) developed lymphoceles. The BMI and number of resected lymph nodes were higher in the lymphocele group, and the use of postoperative radiotherapy was associated with a higher risk of lymphoceles. Thirteen of the 50 patients that developed lymphoceles (n=50) required treatment for lymphocele-related complications.
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Affiliation(s)
- Hee Yeon Kim
- Department of Obstetrics and Gynecology, Yonsei University College of Medicine, Seoul, Korea
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Pitman KT, Ferlito A, Devaney KO, Shaha AR, Rinaldo A. Sentinel lymph node biopsy in head and neck cancer. Oral Oncol 2003; 39:343-9. [PMID: 12676253 DOI: 10.1016/s1368-8375(02)00086-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
In the past decade, the technique of sentinel lymph node biopsy (SLNB) has been applied to a vast array of primary neoplasms, ranging from head and neck melanoma to vulvar carcinoma. At present, experience with SLNB is greatest in patients with melanoma and breast cancer. In view of the well known complications associated with cervical node dissection, it has been suspected for some time that cervical SLNB, if successful, might reduce the morbidity associated with the definitive care of patients with head and neck cancers. This report assesses the current status of SLNB in the treatment of head and neck cancers; while formal investigations of the efficacy of this technique are recommended, SLNB has not yet been demonstrated to possess the same level of utility seen in SLNB in melanoma and breast cancer patients. As a consequence, the application of SLNB to head and neck cancers remains an experimental technique--one which has not yet acquired the status of the standard of patient care.
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Affiliation(s)
- Karen T Pitman
- Department of Otolaryngology, University of Mississippi Medical Center, Jackson, MS, USA
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Fujiwara K, Kigawa J, Hasegawa K, Nishimura R, Umezaki N, Ando M, Itamochi H, Yamaguchi S, Oda T, Terakawa N, Kohshima I, Kohno I. Effect of simple omentoplasty and omentopexy in the prevention of complications after pelvic lymphadenectomy. Int J Gynecol Cancer 2003; 13:61-6. [PMID: 12631222 DOI: 10.1046/j.1525-1438.2003.13029.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This multicenter collaborative study prospectively evaluated the effect of omentoplasty and omentopexy on the prevention of complications after pelvic lymphadenectomy. Sixty-four consecutive patients (42 cervical and 22 endometrial cancer) were enrolled and examined periodically for 12 months. All patients underwent simple, semiradical, or Okabayashi's radical hysterectomy and complete pelvic lymphadenectomy. The infracolic omentum was longitudinally divided in half and omentoplasty was performed so that bilateral omental flaps would reach the pelvic floor. The omental flaps were inserted into the retroperitoneal space and the edges of the flaps were sutured to the psoas muscle. The omental flap was then covered by the peritoneum. Incidence of lymphocele, lymphedema, and severe complications associated with lymphocele, such as infection or urinary stenosis, was evaluated at intervals for at least one year after surgery. Among the 64 patients, 12 patients received pelvic radiation because of occult lymph node metastasis. Planned omentoplasty was not possible in one patient because her omentum was too small; therefore, only unilateral omentopexy was performed. Asymptomatic lymphoceles only were detected by ultrasonogram in 12 patients (18.8%). Three patients (4.7%) had a symptomatic but pressure-only lymphocele. Hydronephrosis and bladder compression probably due to lymphocele were observed in one patient, respectively (3.1%), but resolved within 6 months. Lymphedema was observed in seven patients (10.9%) and persisted for more than 6 months in two patients (3.1%). We conclude that this simple technique of omentoplasty and omentopexy appeared to be effective in reducing the incidence of complications after pelvic lymphadenectomy.
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Affiliation(s)
- K Fujiwara
- Department of Obstetrics and Gynecology, Kawasaki Medical School, Kurashiki-City, Japan.
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Scholz HS, Petru E, Benedicic C, Haas J, Tamussino K, Winter R. Fibrin application for preventing lymphocysts after retroperitoneal lymphadenectomy in patients with gynecologic malignancies. Gynecol Oncol 2002; 84:43-6. [PMID: 11748974 DOI: 10.1006/gyno.2001.6462] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We performed a randomized, prospective trial to assess the impact of fibrin glue on the incidence of lymphocysts after systematic pelvic or pelvic and paraaortic lymphadenectomy in patients with gynecologic malignancies. METHODS Ninety-three consecutive patients with gynecologic pelvic malignancies who underwent surgery including pelvic or pelvic and paraaortic lymphadenectomy were randomized during surgery to be treated with fibrin glue or not. Serial computed tomography (CT) scans were performed during follow-up. CT findings of a smooth and thin-walled cavity filled with a water-equivalent fluid, sharply demarcated from its surroundings and without signs of infiltration were interpreted as lymphocysts. RESULTS Forty-seven patients (51%) were treated with fibrin glue and 46 (49%) were not. All 93 patients underwent pelvic lymphadenectomy; 15 patients (32%) of the fibrin group and 12 (26%) of the controls also underwent paraaortic lymphadenectomy. We found no significant differences between patients who received fibrin glue and those who did not. CONCLUSION Intraoperative application of fibrin glue did not reduce the rate of postoperative lymphocysts after lymphadenectomy and had no impact on any follow-up parameter. Its use seems not to be indicated in systematic gynecologic pelvic or pelvic and paraaortic lymphadenectomy.
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Affiliation(s)
- Heinz S Scholz
- Department of Obstetrics and Gynecology, University of Graz, Auenbruggerplatz 14, Graz, A-8036, Austria.
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Raju S, Papadopoulos A, Devaja O. Necessity of omentoplasty after lymphadenectomy. Gynecol Oncol 2001; 80:107-8. [PMID: 11136582 DOI: 10.1006/gyno.2000.6019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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