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A Systematic Review and Meta-analysis of Techniques for Management of Postoperative Lymphatic Leaks After Groin Surgery. Ann Plast Surg 2022; 89:238-244. [PMID: 35703193 DOI: 10.1097/sap.0000000000003228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Plastic surgeons are often consulted to manage postoperative groin lymphatic leaks that may lead to serious sequelae if not promptly treated. Because there are no standardized guidelines for best treatment practices, this systematic review and meta-analysis evaluates the outcomes of multiple management modalities to ultimately guide decision making for surgeons. METHODS Literature surrounding lymphatic leaks in the groin was reviewed from PubMED, MEDLINE, EMBASE, and the Cochrane Library from January 1, 2000, to December 1, 2020 according to Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. The inciting procedure, postoperative lymphatic complication, used management, and days to resolution were recorded. Pairwise comparisons using the Wilcoxon rank sum test with Bonferroni continuity correction were used to determine which treatment modalities differed significantly and accounted for multiple hypothesis testing. RESULTS A total of 1468 total studies were initially found, which narrowed to 267 unique articles after duplicates were removed. Twelve articles ultimately met the inclusion criteria and were included in the data analysis. There were 264 groin complications, of which 217 were initially treated with conservative management, 81 with a minimally invasive procedure, and 125 with surgery. More than 95% of all cases had an inciting procedure of a vascular nature.For vascular surgery-induced lymphatic leak treated by minimally invasive and surgical techniques, a significantly higher number of cases resolved compared with those treated conservatively (100% and 96.7% compared with 29.5%, respectively, P < 0.05). However, there were no significant differences in the proportion that resolved between the minimally invasive and surgical cases (P = 0.11). Vascular cases that were only managed with surgery had significantly shorter days to resolution compared with cases that first attempted conservative management (P < 0.001). CONCLUSIONS Both minimally invasive and surgical options have increased odds of resolution and lower failure rates compared with conservative management alone. The odds of resolution were higher when treated with more invasive procedures compared with conservative-only management, but the mean days to resolution was longer. This meta-analysis depicts successful resolution with procedural management and supports an initial trial of minimally invasive techniques.
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Diagnosis and Treatment of Lymphatic Complications of the Groin Following Open Lower Extremity Revascularization with Plastic Surgery Closure. Ann Vasc Surg 2021; 82:197-205. [PMID: 34902473 DOI: 10.1016/j.avsg.2021.10.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/14/2021] [Accepted: 10/23/2021] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Lymphatic complications following vascular procedures involving the groin require prompt treatment to limit morbidity. Several treatments have been described, including conservative management, aspiration, sclerotherapy, and direct lymphatic ligation with or without a muscle flap have been described. To date, there is no data indicating which treatment results in the shortest time to recovery. We sought to address this gap by conducting a retrospective cohort study. METHODS We reviewed all patients who developed a lymphatic complication after undergoing an open revascularization procedure in the groin between 2014 and 2020 in which plastic surgery was involved in the closure. A control group consisted of patients from the same timespan who did not develop a lymphatic complication. Demographics, comorbidities, operative details, and outcomes were compared between these groups. For cases identified with a lymphatic complication, the method of diagnosis, culture data, and treatment details were collected, and outcomes were compared for surgical management versus sclerotherapy. RESULTS There were 27 lymphatic complications and 60 control patients. The complication group had a higher incidence of aortofemoral bypass (25.8% vs. 8.3%, p=0.04), and a lower incidence of femoral-to-distal bypass (11.1% vs. 45.0%, p<0.01). Daily drain output volume from postoperative days 1-5, and days 6-10, was significantly higher in the complication group than in the controls (194.0 vs. 44.0, p<0.01; and 429.5 vs. 35.0, p<0.01, respectively). In the lymphatic leak group, 16 patients (59.3%) had surgical treatment and six (22.2%) had sclerotherapy. Of those who had surgery, 71.4% had successful outcomes without the need for an additional intervention, whereas all of the patients analyzed who were treated with sclerotherapy had successful outcomes without further intervention. The average time to resolution was significantly shorter for surgery than for sclerotherapy (38.7 vs. 86.0 days, p=0.03). CONCLUSIONS Daily postoperative drain volume can assist with early diagnosis of a lymphatic leak in the groin following an open revascularization procedure. Sclerotherapy and surgery were each successful, but surgery resulted in significantly shorter times to resolution. In the appropriate candidates, surgery should be considered first line management of a lymphatic leak.
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Vacuum-Assisted Suction Drainage as a Successful Treatment Option for Postoperative Symptomatic Lymphoceles. ROFO-FORTSCHR RONTG 2021; 194:384-390. [PMID: 34649288 DOI: 10.1055/a-1586-3652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE Lymphoceles often occur within several weeks or even months after surgery. Mostly asymptomatic and therefore undiagnosed, they may be self-healing without any treatment. A small percentage of postoperative lymphoceles are symptomatic with significant pain, infection, or compression of vital structures, thus requiring intervention. Many different treatment options are described in the literature, like drainage with or without sclerotherapy, embolization of lymph vessels, and surgical approaches with laparoscopy or laparotomy. Inspired by reports stating that postoperative suction drainage can prevent the formation of lymphoceles, we developed a simple protocol for vacuum-assisted drainage of symptomatic lymphoceles, which proved to be successful and which we would therefore like to present. MATERIALS AND METHOD Between 2008 and 2020, 35 patients with symptomatic postoperative lymphoceles were treated with vacuum-assisted suction drainage (in total 39 lymphoceles). The surgery that caused lymphocele formation had been performed between 8 and 572 days before. All lymphoceles were diagnosed based on biochemical and cytologic findings in aspirated fluid. The clinical and imaging data were collected and retrospectively analyzed. RESULTS In total, 43 suction drainage catheters were inserted under CT guidance. The technical success rate was 100 %. One patient died of severe preexisting pulmonary embolism, sepsis, and poor conditions (non-procedure-related death). In 94.8 % of symptomatic lymphoceles, healing and total disappearance could be achieved. 4 lymphoceles had a relapse or dislocation of the drainage catheter and needed a second drainage procedure. Two lymphoceles needed further surgery. The complication rate of the procedure was 4.6 % (2/43, minor complications). The median indwelling time of a suction drainage catheter was 8-9 days (range: 1-30 days). CONCLUSION The positive effects of negative pressure therapy in local wound therapy have been investigated for a long time. These positive effects also seem to have an impact on suction drainage of symptomatic lymphoceles with a high cure rate. KEY POINTS · Suction drainage of lymphoceles is an easy and successful method to cure symptomatic lymphoceles at various locations.. · We believe this to be due to the induction of cavity collapse and surface adherence.. · In most cases rapid clinical improvement could be obtained.. CITATION FORMAT · Franke M, Saager C, Kröger J et al. Vacuum-Assisted Suction Drainage as a Successful Treatment Option for Postoperative Symptomatic Lymphoceles. Fortschr Röntgenstr 2021; DOI: 10.1055/a-1586-3652.
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Nonoperative Management of a Recurrent Postoperative Inguinal Lymphatic Leak via Negative-Pressure Wound Therapy: A Case Report. Adv Skin Wound Care 2021; 34:1-3. [PMID: 34546209 DOI: 10.1097/01.asw.0000775928.63723.3b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Lymphatic leaks are common following common femoral vessel exposure for cardiac surgical procedures. The management of this complication can be difficult and is often uncomfortable for the patient. This case report describes the successful nonoperative treatment of a recurrent lymphatic leak from an inguinal surgical wound via negative-pressure wound therapy. Negative pressure may be considered a minimally invasive, effective, and acceptable way to treat postoperative lymphatic leaks at the groin.
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Algorithmic approach to the lymphatic leak after vascular reconstruction: a systematic review. Arch Plast Surg 2021; 48:404-409. [PMID: 34352953 PMCID: PMC8342245 DOI: 10.5999/aps.2020.02075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 05/25/2021] [Indexed: 11/08/2022] Open
Abstract
Background To date, there are no consensus guidelines for management of lymphatic leak in groin vascular reconstruction patients. The goal of this study is to review the relevant literature to determine alternatives for treatment and to design an evidence-based algorithm to minimize cost and morbidity and maximize efficacy. Methods A systematic review of the literature was conducted per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Two independent reviewers applied agreed-upon inclusion and exclusion criteria to eligible records. Studies that included patients who underwent groin dissection for oncologic diagnoses and level 5 data were excluded. Interventions were then categorized by efficacy using predetermined criteria. Results Our search yielded 333 records, of which eight studies were included. In four studies, the success of lymphatic ligation ranged from 75% to 100%, with average days to resolution ranging from 0 to 9. Conservative management in the form of elevation, compression, and bedrest may prolong time to resolution of lymphatic leak (14–24 days) and therefore cost. Conclusions The majority of patients should be offered early operative intervention in the form of lymphatic ligation with or without a primary muscle flap. If the patient is not an operative candidate, a trial of conservative management should be attempted before other nonsurgical interventions.
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Lymphovenous Anastomoses and Microscopic Lymphatic Ligations for the Treatment of Persistent Lymphocele. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3407. [PMID: 33680658 PMCID: PMC7929079 DOI: 10.1097/gox.0000000000003407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 12/08/2020] [Indexed: 11/26/2022]
Abstract
Numerous approaches have been employed to treat chronic lymphocele and cutaneous lymphatic fistulas (LFs) with little success. Given a high incidence and substantial consequences for patients, there is an ongoing demand for effective therapeutic and preventive strategies. The aim of this study was to evaluate the results after microscopic lymphatic ligation (MLL) and lymphovenous anastomosis (LVA) as a therapeutic and preventive approach in this context. Methods Demographic data, surgical characteristics, complications, and the overall outcome of all patients undergoing surgery for postoperative LF from 2014 to 2019 were collected retrospectively. Patients were categorized in accordance with predefined inclusion/exclusion criteria and with their treatment. Statistical analysis was conducted using descriptive, summary statistics to identify a central tendency. Results Thirty-four patients underwent indocyanine-green-lymphangiography guided revision surgery for LF. Two patients were lost to follow-up at 6 months. LF was successfully treated in all patients (n = 32) with a multimodal approach. Only MLL was performed in 22 patients and MLL/LVA in 10 patients. LF resolved in 78% of all patients with MLL only or MLL/LVA. In the remaining 22%, LF resolved after additional sclerotherapy within 3 months. Conclusions Treatment of LF should follow a standardized staged surgical approach to optimize outcome. LF was treated successfully in all our patients. We therefore propose a multimodal interdisciplinary approach to this common clinical problem that includes adjunctive sclerotherapy.
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Srinivasan A, Alizadegan S. Venous insufficiency, lymphocutaneous fistula, and use of autologous blood. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2020; 7:61-63. [PMID: 33665533 PMCID: PMC7903192 DOI: 10.1016/j.jvscit.2020.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 10/16/2020] [Indexed: 11/08/2022]
Abstract
Lymphocutaneous fistulas are an uncommon occurrence that can present after surgical intervention in lymphatic-rich areas. A spontaneous lymphatic leak can occur in conjunction with lymphedema or in the vicinity of venous stasis ulcers. However, spontaneous lymphocutaneous fistulas are extremely rare. Traditional treatments have included surgical ligation, negative pressure therapy, and embolization. We present the case of a lymphocutaneous fistula secondary to chronic venous stasis, which was treated via injection of autologous blood and subsequent thrombosis. In the present case report, we have demonstrated successful embolization of a lymphatic vessel via autologous blood injection, a nontraditional technique that, nonetheless, yielded positive and lasting results.
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Affiliation(s)
- Arvind Srinivasan
- Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisc
| | - Shahriar Alizadegan
- Division of Vascular Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisc
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Scaglioni MF, Meroni M, Fritsche E. Lymphovenous anastomosis (LVA) for treatment of iatrogenic lymphocele in the thigh. Microsurgery 2020; 41:19-25. [PMID: 32343453 DOI: 10.1002/micr.30594] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 02/23/2020] [Accepted: 04/17/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Lymphocele is a collection of lymphatic fluid within the body. It is caused by an impairment of lymph drainage and often occurs after a surgical intervention. In this setting conservative treatment is usually ineffective. The aim of this report is to share the outcomes of 11 patients with iatrogenic lymphocele in the thigh area treated by supermicrosurgical lymphovenous anastomosis. PATIENTS AND METHODS Eleven patients presenting iatrogenic lymphocele in the thigh were referred for surgery after an unsuccessful conservative therapy. Patients' mean age was 56 years old, two males and nine females. All of them presented a moderate-to-severe lymphocele in the medial thigh after a surgical intervention that damaged the rich lymphatic pathway present there. Indocyanine green (ICG) lymphography was always performed to visualize the lymphatic vessels and to make the preoperative marking. RESULTS All the 11 patients were successfully treated by means of one or more (range: 1-3; mean: 1.5) lymphaticovenous anastomoses without complications. Three of them also received a pedicled sartorius flap for dead space obliteration. All the patients reached full range of motion (ROM) and no recurrences were observed during follow up (range: 6-12 months; mean: 8). Intra-operative ICG lymphography was performed in all cases to check the patency of the anastomoses. CONCLUSIONS Lymphaticovenous anastomosis confirmed to be a minimally-invasive and effective procedure for the treatment of postsurgical lymphoceles in the leg. For large lymphoceles a muscle flap may be indicated for volume restoration and prevention of recurrences.
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Affiliation(s)
- Mario F Scaglioni
- Depatment of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Matteo Meroni
- Depatment of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Elmar Fritsche
- Depatment of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
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Lymphatic Leaks of the Thigh and Inguinal Region: Combined Plastic Surgery Approaches for an Effective Treatment Algorithm. Ann Plast Surg 2020; 85:661-667. [PMID: 32118638 DOI: 10.1097/sap.0000000000002310] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Surgical procedures interfering with the draining nodes in the inguinal region carry the intrinsic risk of lymphatic complications. Lesions of the inguinal lymphatic network can lead to lymphocele or lymphocutaneous fistulas and can eventually be associated to limb lymphedema with consequent high morbidity. OBJECTIVES This article describes a new surgical algorithm based on wound properties to properly address lymphatic complications of the inguinal area. Based on our experience, surgical solutions ranged from selective lymphatic vessel ligation to microsurgical lymphatic fistula treatment and free tissue transfer. METHODS Fourteen consecutive patients underwent surgery in our department following failed attempts to address persistent lymphatic leaks. Patient characteristics such as smoking, previous surgeries, comorbidities, and wound properties were considered. Identification of the leak was performed using blue patent dye and indocyanine green fluorescence. Surgical reconstruction occurred, according to our algorithm. RESULTS Lymphatic leaks were visualized in 11 of 14 patients. Direct closure of the wound after leak ligation could be performed in 4 of 14 patients. Multilymphatic into vein anastomosis was performed in 3 of 14 patients, and the remaining patients benefited from flap surgery based on the wound defects. All 14 patients had successful outcomes (100%) with early drain removal (average, 6 [SD, 6] days) and definitive wound healing 2 weeks postoperatively. After a mean follow-up of 12 (SD, 2.9) months, no clinical infection, lymphatic complication, or wound breakdown occurred. One patient had a partial recurrence that did not require surgical intervention. CONCLUSIONS A stepwise approach, combining lymphatic surgery principles and plastic surgery flap techniques, can lead to an effective treatment algorithm where surgical options are wound tailored to guarantee the best functional outcomes.
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Supermicrosurgical Lymphaticovenous Anastomosis as an Alternative Treatment Option for Patients with Lymphorrhea. Plast Reconstr Surg 2020; 144:1214-1224. [PMID: 31688769 DOI: 10.1097/prs.0000000000006169] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lymphorrhea is probably the most appalling form of lymphedema and is difficult to treat. Intractable lymphorrhea is prone to infection because of skin breakdown. It is believed that supermicrosurgical lymphaticovenous anastomosis is unsuitable for treating such severe disease. Only a few lymphorrhea patients treated with lymphaticovenous anastomosis have been reported. Whether it can be used to treat lymphorrhea has remained inconclusive. METHODS From September of 2015 to June of 2018, 105 patients underwent supermicrosurgical lymphaticovenous anastomosis (n = 746) in the authors' hospital. These patients are divided into the nonlymphorrhea group (three male and seven female patients) and the nonlymphedema group (lymphedema patients without lymphorrhea) (11 male and 84 female patients). Retrospective chart review with demographic data and intraoperative findings were recorded and analyzed. Post-lymphaticovenous anastomosis outcomes for lymphorrhea patients were also recorded. RESULTS No significant differences were found in patient age, sex, or affected limbs between these two groups. As for intraoperative findings, no differences were found in the percentage of indocyanine green-enhanced lymphatic vessels (52.7 ± 41.1 percent versus 67.3 ± 36.7 percent; p = 0.227) or the pathologic changes of lymphatic vessels based on the normal, ectasis, contraction, and sclerosis type classification (2.2 ± 1.0 versus 2.1 ± 1.0; p = 0.893) between the lymphorrhea and nonlymphorrhea groups, respectively. The average follow-up period was 14.5 months (range, 3 to 31 months). Five lymphorrhea patients (50 percent) showed complete recovery without relapse; significant lymphorrhea reduction was found in three patients (30 percent), and two patients showed minimal improvements (20 percent). CONCLUSION With comparable functional lymphatic vessels identified in lymphorrhea patients, supermicrosurgical lymphaticovenous anastomosis is a viable option for lymphorrhea treatment, with satisfactory results. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Uhl C, Götzke H, Woronowicz S, Betz T, Töpel I, Steinbauer M. Treatment of Lymphatic Complications after Common Femoral Artery Endarterectomy. Ann Vasc Surg 2019; 62:382-386. [PMID: 31449944 DOI: 10.1016/j.avsg.2019.06.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 06/01/2019] [Accepted: 06/02/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND This study analyzes the outcome of lymphatic complications after a standard vascular procedure. METHODS This is a retrospective study including patients who had a lymphatic complication after endarterectomy and patch of the common femoral artery in our clinic between March 2007 and June 2018. Therapy of choice was selected according to wound situation and amount of lymphatic liquid. If signs of a wound infection occurred, a surgical therapy was performed; in all other cases a nonsurgical treatment (conservative treatment, radiotherapy) was chosen. RESULTS We performed 977 index operations, a lymphatic complication occurred in 112 cases (11.5%). In 69 cases the lymphatic complication presented as lymphatic fistula (Group 1), in 43 cases as lymphorrhea from the wound (Group 2). Nonsurgical treatment was done in 66 cases (Group 1: 76.8% vs. Group 2: 30.2%; P < 0.000), and a surgical treatment was necessary in 46 cases (Group 1: 23.2% vs. Group 2: 69.8%; P < 0.000). Indication for surgery was Szilagyi 1 infection in 25 cases, Szilagyi 2 infection in 11 cases, and Szilagyi 3 infection in 10 cases. Patients with Szilagyi 1 infections received negative wound pressure therapy (NWPT). A muscle flap in combination with an NWPT was performed in patients with Szilagyi 2 infections. In Szilagyi 3 infections, the patch was replaced; additionally, a muscle flap and an NWPT were performed. The median hospital stay was 13 days in the nonsurgical group and 22.5 days in the surgical group. We had no bleeding complications and no reinfection during follow-up. The median observation period was 23.0 months. Age ≥80 years was associated with an increased risk for lymphatic complications. CONCLUSIONS The therapy of lymphatic complications should be done in accordance with clinical symptoms. A nonsurgical treatment is often sufficient. However, in cases of a wound infection different surgical treatments are necessary.
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Affiliation(s)
- Christian Uhl
- Department of Vascular Surgery, BHB, Regensburg, Germany.
| | - Hannah Götzke
- Department of Vascular Surgery, BHB, Regensburg, Germany
| | | | - Thomas Betz
- Department of Vascular Surgery, BHB, Regensburg, Germany
| | - Ingolf Töpel
- Department of Vascular Surgery, BHB, Regensburg, Germany
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Giacalone G, Yamamoto T, Hayashi A, Belva F, Gysen M, Hayashi N, Yamamoto N, Koshima I. Lymphatic supermicrosurgery for the treatment of recurrent lymphocele and severe lymphorrhea. Microsurgery 2019; 39:326-331. [DOI: 10.1002/micr.30435] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 01/22/2019] [Accepted: 01/25/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Guido Giacalone
- Department of Lymphatic SurgeryAZ Sint‐Maarten Hospital Mechelen Belgium
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive SurgeryNational Center for Global Health and Medicine (NCGM) Tokyo Japan
| | | | - Florence Belva
- Department of Lymphatic SurgeryAZ Sint‐Maarten Hospital Mechelen Belgium
| | - Mieke Gysen
- Department of Nuclear MedicineH. Hartziekenhuis Mol Belgium
| | - Nobuko Hayashi
- Department of Plastic SurgeryTaiyo‐kai Social Welfare Awachiiki Iryo Center Chiba Japan
| | - Nana Yamamoto
- Department of Plastic and Reconstructive SurgeryNational Center for Global Health and Medicine (NCGM) Tokyo Japan
| | - Isao Koshima
- International Lymphedema CenterHiroshima University Hospital Hiroshima Japan
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Salna M, Takayama H, Garan AR, Kurlansky P, Farr MA, Colombo PC, Imahiyerobo T, Morrissey N, Naka Y, Takeda K. Incidence and risk factors of groin lymphocele formation after venoarterial extracorporeal membrane oxygenation in cardiogenic shock patients. J Vasc Surg 2017; 67:542-548. [PMID: 28822659 DOI: 10.1016/j.jvs.2017.05.127] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 05/24/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Venous-arterial extracorporeal membrane oxygenation (VA-ECMO) is a well-established therapy for refractory cardiopulmonary failure. Femoral cannulation offers a quick and effective means of providing circulatory support but is not without complication. Inflammation or lymphatic disruption at the site of cannulation can cause the formation of lymphoceles, leading to the patient's discomfort and possibly necessitating intervention. The purpose of this study was to evaluate the incidence of in-hospital lymphocele formation in VA-ECMO patients and to identify predictors for their development. METHODS We conducted a single-center retrospective review of 192 patients who underwent femoral VA-ECMO insertion and subsequent decannulation from March 2007 to August 2016 for cardiogenic shock. Baseline demographics, risk factors, and cannulation strategies were examined. Groin lymphocele formation was assessed as the primary outcome. RESULTS Median age was 58 years (interquartile range, 48-67 years) with a median duration of support of 4 days (interquartile range, 2-6 days). Lymphocele formation was identified in 31 patients (16%). Patients who developed lymphoceles were more likely to have post-heart transplantation primary graft dysfunction (PGD) as an indication for ECMO support compared with those who did not (54.2% vs 8%; P < .001). ECMO duration was similar between groups, but lymphocele patients were more likely to have undergone femoral cutdown procedures (68% vs 42%; P = .010). Compared with those PGD patients who did not develop lymphoceles, PGD lymphocele patients had higher rates of diabetes mellitus preoperatively (62% vs 8%; P = .006). Thirteen (42%) patients required surgical incision and drainage, and 4 of these patients (31%) required repeated surgical intervention. CONCLUSIONS Lymphocele formation is relatively common after femoral VA-ECMO. There was a significantly higher incidence of lymphocele formation in diabetic patients requiring support for PGD after heart transplantation.
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Affiliation(s)
- Michael Salna
- Columbia University College of Physicians and Surgeons, New York, NY
| | - Hiroo Takayama
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, NY
| | - Arthur R Garan
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Paul Kurlansky
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, NY
| | - Maryjane A Farr
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Paolo C Colombo
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY
| | - Thomas Imahiyerobo
- Division of Plastic Surgery, Department of Surgery, Columbia University Medical Center, New York, NY
| | - Nicholas Morrissey
- Division of Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, NY
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, NY
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, NY.
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Habermehl D, Habl G, Eckstein HH, Meisner F, Combs SE. [Radiotherapeutic management of lymphatic fistulas : An effective but disregarded therapy option]. Chirurg 2017; 88:311-316. [PMID: 28083600 DOI: 10.1007/s00104-016-0352-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Lymphatic fistulas and lymphoceles are known complications after vascular surgery of the groin and after extended surgical interventions in the pelvic region. Unfortunately, conservative standard therapies are not always successful. OBJECTIVES Evaluation of the therapeutic efficacy and related side effects of percutaneous low-dose irradiation in patients with lymphorrhea and definition of its importance. MATERIAL AND METHODS Current presentation of previously published case series, reviews and guidelines. RESULTS The use of low-dose irradiation therapy with single doses of 0.3-0.5 Gy leads to a cessation of the lymphatic flow in a high percentage of patients when standard therapies do not show a sufficient effect. With cessation of lymphorrhea irradiation should be terminated. Acute side effects have not been reported and the risk of tumor induction is almost negligible. CONCLUSION Low-dose irradiation is an effective and very well-tolerated therapeutic alternative in the treatment of lymphatic fistulas and lymphorrhea when conservative therapies are unsuccessful.
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Affiliation(s)
- D Habermehl
- Klinik für RadioOnkologie und Strahlentherapie, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, München, Deutschland. .,Institut für Innovative Radiotherapie (IRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Oberschleißheim, Deutschland.
| | - G Habl
- Klinik für RadioOnkologie und Strahlentherapie, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, München, Deutschland
| | - H-H Eckstein
- Klinik und Poliklinik für Vaskuläre und Endovaskuläre Chirurgie, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, München, Deutschland
| | - F Meisner
- Klinik und Poliklinik für Vaskuläre und Endovaskuläre Chirurgie, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, München, Deutschland
| | - S E Combs
- Klinik für RadioOnkologie und Strahlentherapie, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, München, Deutschland.,Institut für Innovative Radiotherapie (IRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Oberschleißheim, Deutschland
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Hara H, Mihara M, Anan T, Fukumoto T, Narushima M, Iida T, Koshima I. Pathological Investigation of Acquired Lymphangiectasia Accompanied by Lower Limb Lymphedema: Lymphocyte Infiltration in the Dermis and Epidermis. Lymphat Res Biol 2016; 14:172-80. [DOI: 10.1089/lrb.2016.0016] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- Hisako Hara
- Department of Lymphatic and Reconstructive Surgery, Saiseikai Kawaguchi General Hospital, Saitama, Japan
- Department of Plastic and Reconstructive Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Makoto Mihara
- Department of Lymphatic and Reconstructive Surgery, Saiseikai Kawaguchi General Hospital, Saitama, Japan
| | - Takashi Anan
- Sapporo Dermatopathology Institute, Hokkaido, Japan
| | | | - Mitsunaga Narushima
- Department of Plastic and Reconstructive Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Takuya Iida
- Department of Plastic and Reconstructive Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Isao Koshima
- Department of Plastic and Reconstructive Surgery, The University of Tokyo Hospital, Tokyo, Japan
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16
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Gentileschi S, Servillo M, Salgarello M. Supramicrosurgical lymphatic-venous anastomosis for postsurgical subcutaneous lymphocele treatment. Microsurgery 2015; 35:565-8. [DOI: 10.1002/micr.22478] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Revised: 07/26/2015] [Accepted: 08/10/2015] [Indexed: 11/09/2022]
Affiliation(s)
- Stefano Gentileschi
- Department of Plastic and Reconstructive Surgery; Catholic University Sacred Heart, Policlinico Agostino Gemelli; Rome Italy
| | - Maria Servillo
- Department of Plastic and Reconstructive Surgery; Catholic University Sacred Heart, Policlinico Agostino Gemelli; Rome Italy
| | - Marzia Salgarello
- Department of Plastic and Reconstructive Surgery; Catholic University Sacred Heart, Policlinico Agostino Gemelli; Rome Italy
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17
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Knee lymphocutaneous fistula secondary to knee arthroplasty. Case Rep Orthop 2015; 2014:806164. [PMID: 25580333 PMCID: PMC4279846 DOI: 10.1155/2014/806164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 12/01/2014] [Indexed: 11/23/2022] Open
Abstract
Lower limb lymphorrhea secondary to a surgical procedure is a rare but difficult-to-solve complication. In lower limb, this entity is frequently associated with vascular procedures around the inguinal area. We report on a case of a knee lymphocutaneous fistula secondary to a knee revision arthroplasty. To our knowledge, no previous reports regarding this complication have been published.
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Yamamoto T, Yoshimatsu H, Koshima I. Navigation lymphatic supermicrosurgery for iatrogenic lymphorrhea: supermicrosurgical lymphaticolymphatic anastomosis and lymphaticovenular anastomosis under indocyanine green lymphography navigation. J Plast Reconstr Aesthet Surg 2014; 67:1573-9. [PMID: 25023202 DOI: 10.1016/j.bjps.2014.06.007] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 05/29/2014] [Accepted: 06/09/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Lymphorrhea can occur after surgical intervention to the lymphatic system. Most cases with lymphorrhea can be treated conservatively, but some cases are refractory to conservative treatments and require further surgical treatments. METHODS Eight patients developed inguinal lymphorrhea after surgical intervention in the groin region. Navigation lymphatic supermicrosurgery (NLS) was performed for the treatment of iatrogenic lymphorrhea refractory to conservative treatments. Lymphatic vessels ruptured in a lymphorrhea lesion were identified under intraoperative indocyanine green (ICG) lymphography navigation and were anastomosed to a recipient vessel; an intact lymphatic vessel or a vein was selected as a recipient. Feasibility and efficacy of the method were evaluated. RESULTS Among eight inguinal lymphorrhea patients, four patients with refractory lymphorrhea underwent NLS under local anesthesia. In all cases, a lymphatic vessel that caused an intractable lymphorrhea was successfully anastomosed to a recipient vessel (to an intact lymphatic vessel in one case, and to a venule in three cases), and the lymphorrhea was completely cured without lymphorrhea recurrence or lymphedema development. Treatment duration in NLS was significantly shorter than that in conservative treatments (5.0 ± 2.4 vs. 30.0 ± 8.1 days, P = 0.006). CONCLUSIONS Intraoperative ICG lymphography helps a surgeon to find lymphatic vessels in and near a lymphorrhea lesion, which allows secure and easier treatment for an intractable lymphorrhea with preservation of lymph drainage function.
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Affiliation(s)
- Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, The University of Tokyo, Tokyo, Japan; Department of Plastic Surgery, Noda Hospital, Chiba, Japan.
| | - Hidehiko Yoshimatsu
- Department of Plastic and Reconstructive Surgery, The University of Tokyo, Tokyo, Japan
| | - Isao Koshima
- Department of Plastic and Reconstructive Surgery, The University of Tokyo, Tokyo, Japan
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19
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Twine CP, Lane IF, Williams IM. Management of Lymphatic Fistulas After Arterial Reconstruction in the Groin. Ann Vasc Surg 2013; 27:1207-15. [DOI: 10.1016/j.avsg.2013.01.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2012] [Revised: 01/04/2013] [Accepted: 01/09/2013] [Indexed: 12/24/2022]
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20
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Vascular complications and special problems in vascular trauma. Eur J Trauma Emerg Surg 2013; 39:569-89. [DOI: 10.1007/s00068-013-0336-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 09/30/2013] [Indexed: 12/17/2022]
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21
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Boccardo F, Dessalvi S, Campisi C, Molinari L, Spinaci S, Talamo G, Campisi C. Microsurgery for groin lymphocele and lymphedema after oncologic surgery. Microsurgery 2013; 34:10-3. [DOI: 10.1002/micr.22129] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2013] [Revised: 03/22/2013] [Accepted: 03/29/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Francesco Boccardo
- Department of Surgery-Unit of Lymphatic Surgery; IRCCS S.Martino University Hospital-IST; Genoa Italy
| | - Sara Dessalvi
- Department of Surgery-Unit of Lymphatic Surgery; IRCCS S.Martino University Hospital-IST; Genoa Italy
| | - Corrado Campisi
- Department of Surgery-Unit of Plastic and Reconstructive Surgery; IRCCS S.Martino University Hospital-IST; Genoa Italy
| | - Lidia Molinari
- Department of Surgery-Unit of Lymphatic Surgery; IRCCS S.Martino University Hospital-IST; Genoa Italy
| | - Stefano Spinaci
- Department of Surgery-Unit of Lymphatic Surgery; IRCCS S.Martino University Hospital-IST; Genoa Italy
| | - Giuseppina Talamo
- Department of Surgery-Unit of Lymphatic Surgery; IRCCS S.Martino University Hospital-IST; Genoa Italy
| | - Corradino Campisi
- Department of Surgery-Unit of Lymphatic Surgery; IRCCS S.Martino University Hospital-IST; Genoa Italy
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