Large or persistent lymphocyst increases the risk of lymphedema, lymphangitis, and deep vein thrombosis after retroperitoneal lymphadenectomy for gynecologic malignancy

Intra-lymphocele microsurgical identification of causative afferent vessels for effective lymphaticovenular anastomosis in lymphocele treatment: A case report

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.

Postoperative lymphocyst formation after pelvic lymphadenectomy for gynecologic cancers: comparison between laparoscopy and laparotomy

PURPOSE

The goal of this study was to evaluate, using definitive diagnostic criteria, the incidence of lymphocyst formation following pelvic lymphadenectomy for gynecological cancer, and to compare rates between the approaches of laparoscopy and laparotomy.

METHODS

We retrospectively reviewed the medical records of all patients who underwent pelvic lymphadenectomy for cervical or endometrial cancer between March of 2010 and March of 2016. We defined a lymphocyst as a circumscribed collection of fluid within the pelvic cavity, with a diameter of 2 cm or more, as diagnosed with ultrasound or computed tomography.

RESULTS

During the six-year observational period, a pelvic lymphadenectomy was conducted in 196 women with clinical stage I uterine cancer; 90 cases underwent laparoscopy, 106 underwent laparotomy. The minimally invasive laparoscopic group had a lower estimated blood loss (p < 0.01), shorter hospital stay (p < 0.01). Lymphocysts were observed in 14.4% (13/90) of the laparoscopy cases, and in 15.1% (16/106) of the laparotomy cases which means no significant difference of lymphocyst (p = 1.00). The median size of symptomatic lymphocyst was significantly larger in laparotomy group than in laparoscopy group (4.8 cm v.s. 2.8 cm, median) (p = 0.04). Symptomatic lymphocysts were more common in laparotomy [7/90 (7.8%) vs 14/106 (13.2%) (p = 0.253)].

CONCLUSIONS

In a retrospective analysis with a strict diagnostic criteria, we could find no statistical difference in lymphocyst occurrence between laparoscopy and laparotomy. The median size of the lymphocyst was bigger and lymphocyst was likely to be symptomatic in the laparotomy group.

Treatment and Impact of Cervical-Cancer-Related Lymphatic Disorders on Quality of Life and Sexuality Compared with Controls

Background: Lymphatic disorders are frequent complications related to treatment for cervical cancer (CC). The aims of the study are to evaluate the impact of lymphatic disorders on quality of life (QOL) and sexuality in CC survivors after the completion of oncological treatment and to compare them with controls. Methods and Results: An ambispective cohort study was performed by using the Functional Assessment Cancer Therapy (FACT)-Cervix (Cx) fourth version, the World Health Organization Quality of Life-Brief Version (WHOQOL-BREF), and the Female Sexual Function Index (FSFI). Twelve patients affected by lymphatic disorders comprised the study group, 251 comprised the CC control group, and 185 comprised the non-CC control group. Regarding QOL, there were no statistically significant differences between the lymphatic disorder-unaffected and non-CC control groups, except in the WHOQOL-BREF environment domain. A weak positive correlation between lymphatic disorder and FACT-Cx additional concerns (σ = 0.135) was observed. Regarding sexuality, a weak negative correlation was detected between lymphatic disorders and FSFI sexual satisfaction (σ = -0.200) and a weak positive correlation was observed between lymphatic disorders and FSFI dyspareunia (σ = 0.148). We did not observe statistically significant differences in QOL satisfaction between the lymphatic disorder-affected and non-CC control groups. Symptomatic controls reported significantly higher physical health scores than the lymphatic disorder-affected group (p < 0.05). Regarding the psychological domain, the asymptomatic controls obtained significantly higher scores than the lymphatic disorder-affected group (p = 0.003). Conclusions: Lymphatic disorders notably influenced the QOL of CC survivors compared with the non-CC control groups. Lymphatic disorders had a significant negative impact on physical and psychological health. Sexuality was scarcely affected by lymphatic disorders.

Incidence and univariate models for lymphatic drainage disorders following management for cervical cancer

AIM

To clarify the incidence of lymphatic drainage disorders (LLD) after treatment for cervical cancer (CC) and to establish univariate models for their occurrence.

METHODS

A total of 263 eligible patients with CC were identified between 2010 and 2019. We conducted a case-control study and divided the study population into two subsamples of 12 and 251 CC survivors based on the presence/absence of LLD, respectively. The cumulative incidence was evaluated using the Kaplan-Meier method. Univariate models based on Pearson correlation coefficient were used to evaluate associations between explanatory variables and LLD.

RESULTS

The cumulative incidence of LLD began at 3.3% after the 7-month follow-up, reaching a plateau of 21.2% between 130 and 250 months of follow-up. We detected correlation between LLD and number of removed para-aortic lymph nodes (r = -0.39), number of pelvic lymphadenopathies (r = 0.16), pelvic lymphadenectomy (PL) (r = 0.16), age at diagnosis of CC (r = -0.1) and primary surgery (r = 0.1).

CONCLUSION

We observed a cumulative incidence of LLD of 21.2%, which is in accord with other retrospective studies. Number of removed para-aortic lymph nodes, number of pelvic lymphadenopathies, PL, age at diagnosis of CC and primary surgery were the most influential clinical factors associated with the occurrence of LLD in CC survivors.

Comparison of Postoperative Benign Pelvic Cysts Occurred after Gynecologic or Gyne-oncologic Surgery Treated with Percutaneous Transcatheteric Sclerosant Alcohol Therapy

Objectives:

Here, we compare the success of percutaneous transcatheter sclerosant alcohol therapy (PTSAT) for the postoperative treatment of benign pelvic cysts that occurred after gynecologic surgery.

Materials and Methods:

The study is a retrospective case–control trial. Gynecological patients who had symptoms due to postoperative pelvic cysts and received PTSAT after gynecologic surgery, between October 2008 and January 2018, were examined in a single training and research hospital in Turkey. Some factors were investigated for associations with postoperative pelvic cyst formation in patients who underwent gynecologic operations for malignancies or benign conditions. Statistical analysis used: The association between two independent and nonnormally distributed continuous variables was analyzed with the Mann–Whitney U-test. Spearman's rho correlation analysis was conducted to determine the correlation of two nonnormally distributed variables. Chi-square (or Fisher's exact test, when more suitable) was used to examine the correlation between categorical variables.

Results:

Statistically significant differences were found in terms of the average age was higher in patients with malignancies, and the average postoperative pelvic cyst detection time was higher in patients with benign pelvic cysts. While all patients were treated with PTSAT, repetitive PTSAT was required for seven benign and ten malign cases.

Conclusion:

Patients with pelvic cysts that occurred after gynecologic surgery for malignant conditions, large volume pelvic cysts and patients with benign cysts who underwent more than one surgery required recurrent PTSAT.

Microbiological analysis of infectious lymphocele: Case series and literature review

BACKGROUND

Infectious lymphocele is a rare post-operative complication of abdominal surgery, and few studies have focused on its causative organisms. The aim in this research is to clarify microbiology and appropriate empiric treatment of infective lymphocele.

METHODS

We performed a single center, retrospective observational study between April 2000 and March 2018 with a case review and literature search. Data were collected in a chart review.

RESULTS

Twenty-four cases were founded in our institution. 153 cases, including 16 cases from our institution, that detected causative organisms was also analyzed. Infectious lymphocele was found to occur post gynecological/urological surgery in cancer patients. We also reported that bacteremia incidence and the mortality rate of infectious lymphocele cases were very low. The major sites of infectious lymphocele were pelvis or inguinal area. Our case series and literature review showed Gram positive cocci were the major causative organisms, with Staphylococcus aureus constituting one third of them (53/153 cases). Streptococcus species (26/153cases) and coagulase negative Staphylococci (17/153 cases) were the second and third most detected organisms.

CONCLUSION

In gynecologic and urologic cancer patients, Gram positive cocci were the most common organisms causing lymphocele infection. Gram-positive coverage might be reasonable for empiric therapy in infectious lymphocele.

Bilateral abdominopelvic lymphoceles secondary to huge uterine leiomyomas: A case report

Pelvic lymphocele secondary to uterine leiomyoma has not been previously reported. We report a case of abdominopelvic lymphocele associated with huge uterine fibroids which was managed conservatively. A 39-year-old unmarried lady presented with pressure symptoms in pelvis was diagnosed to have a huge uterine leiomyomas occupying the entire abdomen. Magnetic resonance imaging of pelvis and abdomen demonstrated multiple uterine fibroids. In addition, bilateral cystic structures were seen in the pelvis with extension to the para-colic gutters. During myomectomy, bilateral abdominopelvic lymphoceles were noted which required only fine-needle aspiration. Follow up abdominal ultrasound at 6 weeks, demonstrated spontaneous resolution of these lesions. The pressure exerted by these huge uterine leiomyomas might have possibly obstructed the lymphatic drainage leading to bilateral abdominopelvic lymphoceles. These secondary lymphoceles resolve spontaneously and does not need any further diagnostic procedures or surgical interventions.

Risk factors, microbiology and management of infected lymphocyst after lymphadenectomy for gynecologic malignancies

Objective

To evaluate risk factors, microbiology and management of infected lymphocysts in patients undergoing systemic lymphadenectomy for gynecological cancer.

Methods

Patients with gynecological cancer who developed postoperative lymphocysts after lymphadenectomy were enrolled between January 2009 and June 2017. The clinical data of infected lymphocysts were analyzed and compared with non-infected lymphocysts. Multivariate analysis of risk factors, the microbiology and therapeutic strategies for infected lymphocysts were also evaluated.

Results

A total of 115 patients out of 619 developed postoperative lymphocysts, the incidence of infected lymphocysts was 4.36%. Infected lymphocysts were more frequently found in patients with combined pelvic and para aortic lymphadenectomy, higher number of resected pelvic lymph nodes, lower level of postoperative serum hemoglobin and higher proportion of neutropenia. The median diameter of infected lymphocysts was significantly larger than non-infected (71.89 vs 38.47 mm, P < 0.001) and a large size (diameter over 60 mm) was identified as an independent risk factor for infected lymphocysts (OR = 3.933, P = 0.017). The microbiology of infected lymphocysts includes gram-positive cocci, gram-negative bacillus and anaerobic bacteria. Percutaneous catheter drainage was successfully performed in 20 patients with infected lymphocysts. 16 of 19 patients with large lymphoceles received combined antibiobics and PCD therapy and showed clinical remission in all cases. Patients with large size infected lymphocysts who received combined therapy experienced a significantly shorter treatment period and lower recurrent rate than those with only antibiotics (P = 0.046, P = 0.018).

Conclusions

The current study demonstrated that a diameter over 60 mm was an independent risk factor for infected lymphocysts. The predominant bacteria originated from the urogenital or skin flora. The combination of PCD with appropriate antibiotics was a convenient and effective therapeutic strategy resulting in a high success rate.

Use of lymphoscintigraphy to differentiate primary versus secondary lower extremity lymphedema after surgical lymphadenectomy: a retrospective analysis

Background

When managing patients with cancer, lymphedema of the lower limbs (LLL) is commonly reported as secondary to the surgical excision and/or irradiation of lymph nodes (LNs). In the framework of lymphoscintigraphic imaging performed to evaluate secondary LLL, some lympho-nodal presentations have been observed that could not be explained by the applied treatments, suggesting that these LLL might be primary. Therefore, all our lymphoscintigraphic examinations that were performed in patients for LLL after surgery for gynecological or urological cancer were retrospectively analyzed in order to evaluate the frequency in which these LLL might not be secondary (either completely or partially) but primary in origin.

Methods

Lymphoscintigraphies performed in 33 patients who underwent LN dissection (limited to the intra-abdominal LN) with or without radiotherapy for histologically confirmed ovarian cancer (n = 6), uterine cancer (n = 14 with cervical cancer and n = 7 with endometrial cancer), or prostate cancer (n = 6) were compared to lymphoscintigraphies obtained in primary LLL.

Results

In 12 (33% of the) patients (3 men plus 9 women, 4 with cervical cancer and 5 with endometrial cancer), scintigraphy of the lower limbs revealed lympho-nodal presentation that did not match with the expected consequences of the surgical and/or radiological treatments and were either suggestive or typical of primary lymphedema.

Conclusions

This retrospective analysis of a limited but well-defined series of patients suggests that the appearance of LLL might not be related to cancer treatment(s) but that these LLL may represent the development of a primary lymphatic disease latent prior to the therapeutic interventions.

Lymphatic dysfunction after ligation surgery for varicose vein

Objective:

Although the lymphatic complications such as lymphocele sometimes occur after surgery for varicose veins, the lymphatic function of such patients has not been evaluated. In this case report, we present a case of lymphocele after ligation surgery for varicose vein. We also detected subclinical dysfunction in lower limb using indocyanine green (ICG) lymphography.

Case report:

A 76 year- old female underwent ligation surgery for right lower leg varicose vein, and she noticed the squashy lesion in the medial side of the right knee. Three years later, she consulted our clinic and we performed ICG lymphography. We observed dermal backflow around the mass, which indicated lymphatic dysfunction. After injecting additional ICG around the knee, we punctured and drained the clear, yellow fluid from the mass and it was contrasted with ICG during the examination and the involvement of the lymphatic system was proven.

Optimal timing for drainage of infected lymphocysts after lymphadenectomy for gynecologic cancer

BACKGROUND

A lymphocyst (lymphocele) is a common complication of lymphadenectomy, which is a widely used surgical method for gynecologic cancers. In cases of infected lymphocysts, therapeutic strategies, including the timing and duration of antibiotics administration and cyst drainage, may vary depending on the physician. The aim of this study was to determine the optimal timing for drainage of lymphocysts infected with bacteria resistant to antibiotic treatment.

MATERIALS AND METHODS

Clinical data for 1175 patients who underwent a lymphadenectomy as part of surgery for a gynecologic malignancy between April 2000 and August 2012 at Osaka University Hospital, Osaka, Japan, were analyzed.

RESULTS

Of the 282 patients who developed a lymphocyst (24%), 35 with infected lymphocysts (12%) were analyzed. Lymphocyst infection was not associated with tumor origin, type of hysterectomy, or region of lymphadenectomy (P = 0.81, P = 0.59, and P = 0.86, respectively). The total treatment period of cases treated only with antibiotics tended to be shorter than that of cases treated with combined antibiotics and drainage, but the difference was not significant (P = 0.061). However, for severe cases which needed drainage, initiating the drainage by day 5 significantly shortened the total treatment period compared with cases started on or after day 6 (P = 0.042).

CONCLUSIONS

The appropriate time point for initiating lymphocyst drainage has been difficult to determine. The present study implies that for severe lymphocyst infections, where drainage is required in addition to antibiotics, the earlier the drainage is performed, the shorter the treatment period is. Further studies may be required to decide other optimal treatment strategies for infected lymphocysts.