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Gómez FM, Baetens TR, Santos E, Rocha BL, Horwitz B, Lojo-Lendoiro S, Vargas P, Patel P, Beets-Tan R, Martínez-Rodrigo JJ, Bonmatí LM. Interventional solutions for post-surgical problems: a lymphatic leaks review. CVIR Endovasc 2024; 7:61. [PMID: 39126551 PMCID: PMC11316727 DOI: 10.1186/s42155-024-00473-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 08/01/2024] [Indexed: 08/12/2024] Open
Abstract
The lymphatic circulation plays a crucial role in maintaining fluid balance and supporting immune responses by returning serum proteins and lipids to the systemic circulation. Lymphatic leaks, though rare, pose significant challenges post-radical neck surgery, oesophagectomy, and thoracic or retroperitoneal oncological resections, leading to heightened morbidity and mortality. Managing lymphatic leaks necessitates consideration of aetiology, severity, and volume of leakage. Traditionally, treatment involved conservative measures such as dietary restrictions, drainage, and medical management, with surgical intervention reserved for severe cases, albeit with variable outcomes and extended recovery periods. Lymphography, introduced in the 1950s, initially served as a diagnostic tool for lymphoedema, lymphoma, tumour staging, and monitoring chemotherapy response. However, its widespread adoption was impeded by alternative techniques like Computed Tomography, learning curves, and its associated complications. Contemporary lymphatic interventions have evolved, favouring nodal lymphangiography over pedal lymphangiography for its technical simplicity and reduced complexity. Effective management of chylous leaks mandates a multimodal approach encompassing clinical evaluation and imaging techniques. In cases where conservative management proves ineffective, embolization through conventional lymphangiography by bipedal dissection or intranodal injection emerges as a viable option. This review underscores the importance of a comprehensive approach to diagnosing and treating lymphatic leaks, highlighting advancements in imaging and therapeutic interventions that enhance patient outcomes.
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Affiliation(s)
- Fernando M Gómez
- Biomedical Imaging Research Group (GIBI2^30), La Fe Health Research Institute (IIS La Fe), Avenida Fernando Abril Martorell, València, 46026, Spain.
- Radiology Department, La Fe University and Polytechnic Hospital, Avenida Fernando Abril Martorell, València, 46026, Spain.
- Department of Radiology, The Netherlands Cancer Institute, Plesmanlaan 121, Amsterdam, 1066 CX, The Netherlands.
| | - Tarik R Baetens
- Department of Radiology, The Netherlands Cancer Institute, Plesmanlaan 121, Amsterdam, 1066 CX, The Netherlands
| | - Ernestos Santos
- Radiology, Division of Interventional Radiology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Boris León Rocha
- Department of Interventional Radiology, Hospital Clínico de la Universidad de Chile, Santos Dumont 999, Independencia, Región Metropolitana, Chile
| | - Benjamín Horwitz
- Radiology Department, Facultad de Medicina Clínica Alemana-Universidad del Desarrollo, Santiago, 7650568, Chile
| | - Sara Lojo-Lendoiro
- Department of Radiology, Hospital Álvaro Cunqueiro, Estrada de Clara Campoamor, 341, Vigo, Pontevedra, 36312, Spain
| | - Patricio Vargas
- Radiology Department, Facultad de Medicina Clínica Alemana-Universidad del Desarrollo, Santiago, 7650568, Chile
| | - Premal Patel
- Great Ormond Street Hospital for Children NHS Foundation Trust, Renal Unit, Level 7, Southwood Building, Great Ormond Street, London, WC1N 3JH, UK
| | - Regina Beets-Tan
- Department of Radiology, The Netherlands Cancer Institute, Plesmanlaan 121, Amsterdam, 1066 CX, The Netherlands
| | - José J Martínez-Rodrigo
- Biomedical Imaging Research Group (GIBI2^30), La Fe Health Research Institute (IIS La Fe), Avenida Fernando Abril Martorell, València, 46026, Spain
| | - Luis Martí Bonmatí
- Biomedical Imaging Research Group (GIBI2^30), La Fe Health Research Institute (IIS La Fe), Avenida Fernando Abril Martorell, València, 46026, Spain
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Ishii N, Harimoto N, Seki T, Muranushi R, Hagiwara K, Hoshino K, Tsukagoshi M, Watanabe A, Igarashi T, Shibuya K, Araki K, Shirabe K. The impact of lymphangiograpy on chyle leakage treatment duration after pancreatic surgery. Surg Today 2024; 54:651-657. [PMID: 38062229 DOI: 10.1007/s00595-023-02777-8] [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: 08/01/2023] [Accepted: 10/10/2023] [Indexed: 05/21/2024]
Abstract
PURPOSE Chyle leakage (CL) is a common complication in pancreatic surgery. Lymphangiography is a therapeutic option for CL in cases of conservative treatment failure. This study investigated the effect of lymphangiography on the healing time of CL. METHODS We retrospectively evaluated 283 patients who underwent pancreatic resection between January 2016 and June 2022. The risk factors for CL and the treatment period were evaluated according to whether or not lymphangiography was performed. RESULTS Of the 29 patients (10.2%) that had CL, lymphangiography was performed in 6. Malignant disease, the number of harvested lymph nodes, and drain fluid volume on postoperative day 2 were identified as independent risk factors for CL. Lymphangiography was associated with the cumulative healing rate of CL, and patients who underwent lymphangiography had a significantly shorter treatment period. No lymphangiography-related adverse events were observed. CONCLUSION Lymphangiography is a feasible and safe treatment option for CL. The CL treatment period after pancreatic surgery was significantly shorter in patients who underwent lymphangiography than in those who did not. Our results suggest that lymphangiography may contribute to early improvement of persistent CL.
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Affiliation(s)
- Norihiro Ishii
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Norifumi Harimoto
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan.
| | - Takamomi Seki
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Ryo Muranushi
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Kei Hagiwara
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Kouki Hoshino
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Mariko Tsukagoshi
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Akira Watanabe
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Takamichi Igarashi
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Kei Shibuya
- Department of Diagnostic Radiology and Nuclear Medicine, Graduate School of Medicine, Gunma University, Gunma, Japan
| | - Kenichiro Araki
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Ken Shirabe
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
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Verhaeghe L, Holsbeeck AV, Bonne L, Claus E, Marrannes J, Vandenbulcke R, Jochmans I, Pirenne J, Maleux G. Therapeutic lymphangiography with ethiodized oil for the management of lymphoceles and chylous ascites. Diagn Interv Imaging 2023; 104:500-505. [PMID: 37210283 DOI: 10.1016/j.diii.2023.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/28/2023] [Accepted: 05/06/2023] [Indexed: 05/22/2023]
Abstract
PURPOSE The purpose of this study was to analyze the safety, technical success and clinical outcome of percutaneous intranodal ethiodized oil (Lipiodol®) based lymphangiography (L-LAG) for the management of refractory pelvic lymphoceles or chylous ascites using high doses of ethiodized oil. MATERIALS AND METHODS Thirty-four patients presenting with symptomatic, refractory postoperative pelvic lymphocele or chylous ascites referred for theranostic, inguinal, intranodal L-LAG treatment between May 2018 and November 2021 were retrospectively included. There were 21 men and 13 women, with a mean age of 62.7 ± 16.2 (standard deviation) years (age range: 9-86 years), who underwent a total of 49 L-LAG for the management of lymphoceles (n = 14), chylous ascites (n = 18) or a combination of lymphocele and chylous ascites (n = 2). Clinical and radiological pre-interventional, procedural and follow-up data up to January 2022 were collected from patients' electronic medical records and imaging files. RESULTS Technical success was obtained in 48 out of 49 L-LAG (98%). No complications related to L-LAG were noted. After one or more L-LAG, clinical success was obtained in 30 patients (88%) with a mean of 1.4 interventions per patient and mean intranodal injected volume of 29 mL of ethiodized oil per session. The remaining four patients (12%), with one or more failed L-LAG, underwent additional surgical intervention to definitively treat the postoperative lymphatic leakage. CONCLUSION L-LAG using high doses of ethiodized oil is a minimally invasive, safe and effective treatment of postoperative pelvic lymphocele or chylous ascites. Multiple sessions may be needed to obtain a meaningful clinical result.
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Affiliation(s)
- Laurence Verhaeghe
- Department of Radiology, General Hospital AZ Sint-Lucas/Sint-Jan, 8310 Bruges, Belgium; Department of Radiology, University Hospitals KU Leuven, 3000 Leuven, Belgium
| | - Andries Van Holsbeeck
- Department of Radiology, General Hospital AZ Sint-Lucas/Sint-Jan, 8310 Bruges, Belgium
| | - Lawrence Bonne
- Department of Radiology, University Hospitals KU Leuven, 3000 Leuven, Belgium
| | - Eveline Claus
- Department of Radiology, University Hospitals KU Leuven, 3000 Leuven, Belgium
| | - Jesse Marrannes
- Department of Radiology, General Hospital AZ Sint-Lucas/Sint-Jan, 8310 Bruges, Belgium
| | - Ruben Vandenbulcke
- Department of Radiology, General Hospital AZ Delta, 8800 Roeselare, Belgium
| | - Ina Jochmans
- Department of Abdominal Transplantation Surgery, University Hospitals KU Leuven, 3000 Leuven, Belgium
| | - Jacques Pirenne
- Department of Abdominal Transplantation Surgery, University Hospitals KU Leuven, 3000 Leuven, Belgium
| | - Geert Maleux
- Department of Radiology, University Hospitals KU Leuven, 3000 Leuven, Belgium.
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Pecorelli N, Guarneri G, Palucci M, Gozzini L, Vallorani A, Crippa S, Partelli S, Falconi M. Early biochemical predictors of clinically relevant pancreatic fistula after distal pancreatectomy: a role for serum amylase and C-reactive protein. Surg Endosc 2022; 36:5431-5441. [PMID: 34988737 DOI: 10.1007/s00464-021-08883-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 11/16/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Recent evidence suggests that pancreatic inflammation plays a pivotal role in the occurrence of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy but few data are available for distal pancreatectomy (DP). The aim of this study was to evaluate the impact of early biochemical markers on the occurrence of CR-POPF after DP. METHODS Clinical and laboratory data for 432 consecutive DP patients were reviewed. Serum amylase was evaluated on postoperative day (POD) 1, and drain fluid amylase (DFA) and C-reactive protein (CRP) were evaluated on POD 2 and 3. Receiver operator characteristic (ROC) curves were performed for all biochemical markers and an area under the curve (AUC) was computed. Multivariable regression analyses to identify the factors associated with CR-POPF and severe postoperative morbidity (Clavien-Dindo grade ≥ 3) were performed. RESULTS At 90 days after surgery, CR-POPF occurred in 155 (36%) patients, severe complications in 66 (15%) patients. ROC curve analyses showed that DFA on POD2 had the largest AUC (0.753, p < 0.001), followed by serum amylase on POD 1 (0.651, p < 0.001), serum CRP on POD3 (0.644, p < 0.001), and CRP change between POD 2 and POD 3 (0.644, p < 0.001). Multivariable analysis identified male gender (OR 2.29, 95% CI 1.36-3.86; p = 0.002), DFA ≥ 1500 U/L on POD2 (OR 4.63, 95% CI 2.72-7.89; p < 0.001), serum amylase ≥ 100 U/L on POD 1 (OR 1.72, 95% CI 1.01-2.93; p = 0.046), and CRP increase by at least 25 mg/L on POD 3 compared to the previous day (OR 1.89, 95% CI 1.11-3.21; p = 0.019) as independent predictors of CR-POPF, yielding a valid regression model (AUC 0.765, 95% CI 0.714-0.816, p < 0.001). CONCLUSIONS Postoperative serum amylase and CRP trajectory represent useful early biochemical markers for CR-POPF in addition to DFA. Our findings suggest that these laboratory tests should be incorporated into clinical practice to aid postoperative patient and drain management.
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Affiliation(s)
- Nicolò Pecorelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milano, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Guarneri
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milano, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | | | | | | | - Stefano Crippa
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milano, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Stefano Partelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milano, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milano, Italy. .,Vita-Salute San Raffaele University, Milan, Italy.
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