Experience of Lymphangiography as a Therapeutic Tool for Lymphatic Leakage After Kidney Transplantation

Therapeutic lymphangiography with ethiodized oil for the management of lymphoceles and chylous ascites

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.

A Systematic Review and Meta-analysis of Techniques for Management of Postoperative Lymphatic Leaks After Groin Surgery

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.

Minimal invasive treatment for post-liver and renal transplant lymphatic leaks

INTRODUCTION

Persistent lymphatic leakage from the surgical drain is a troubling complication occasionally encountered postoperatively. This study investigated lymphatic leaks after renal or liver transplantation, comparing the treatment efficacy of traditional catheter drainage vs. minimally invasive lymphatic interventions. We also discuss access and treatment targets considering the physiology of lymphatic flow.

METHODS

Between September 2018 and September 2020, 13 patients with lymphatic leakage were treated with minimally invasive lymphatic interventions; 11 had received a renal transplant, and two received a liver transplant. The control group included 10 patients with post-renal transplant lymphatic leakage treated with catheter drainage. The treatment efficacy of catheter drainage, lymphatic interventions, and different targets of embolization were compared.

RESULTS

The technical success rate for lymphatic intervention was 100%, and the clinical success rate was 92%, with an 82.9% percent reduction in drain volume on the first day after treatment. The duration to reach clinical success was 5.9 days with lymphatic intervention, and 33.9 days with conservative catheter drainage.

CONCLUSION

Lymphangiography and embolization are minimally invasive and efficient procedures for treating persistent lymphatic leaks after renal or liver transplantation. We suggest prompt diagnosis and embolization at upstream lymphatics to reduce the duration of drain retention, days of hospitalization and associated comorbidities. This article is protected by copyright. All rights reserved.

A Novel Technique Using Fluorescent Ureteral Catheter and Flexible Ureteroscope for Safe Laparoscopic Fenestration of Lymphocele after Kidney Transplantation

Laparoscopic fenestration of a postrenal transplant lymphocele is associated with a risk of renal hilar vessel and ureteral injury. Consequently, determination of the incision line is difficult. We describe a case of a 73-year-old man with postrenal transplant lymphocele who underwent a laparoscopic fenestration. We report a surgical video containing a new technique of laparoscopic fenestration using a fluorescent ureteral catheter in combination with a flexible ureteroscope. The combination of a fluorescent ureteral catheter and flexible ureteroscope during surgery enabled us to determine the incision line safely and accurately. Intraoperative real-time visualization of the lymphocele and ureter using a fluorescent ureteral catheter and a flexible ureteroscope is safer than conventional methods for laparoscopic fenestration. To the best of our knowledge, this is the first report of this novel technique.

Treatment of Postoperative Lymphatic Leakage Applying Transpedal Lymphangiography - Experience in 355 Consecutive Patients

PURPOSE

 Report of experience from a single institution in treating postoperative lymphatic leakage (PLL) applying conventional transpedal lymphangiography (TL).

MATERIALS AND METHODS

 453 patients with the initial diagnosis of PLL receiving TL between 03/1993 and 09/2018 were identified in the database. Only patients with confirmed PLL were included in the study. The technical success, safety, and treatment success of TL were evaluated. Independent predictors of TL treatment failure were examined using univariate and multivariate logistic regression analysis.

RESULTS

 355 consecutive patients (218 men, 137 women; median age of 62 years) who underwent TL for PLL (e. g., chylothorax) after ineffective conservative treatment were included. The median time between causal surgery and TL was 27 days. The median technical success rate of TL was 88.5 %, with a median volume of Lipiodol of 10.0 ml. No complication of TL was recorded. Three groups were defined according to the different clinical courses: group A (41/355, 11.5 %) - TL with technical failure; group B (258/355, 72.7 %) - "therapeutic" TL alone with technical success; and group C (56/355, 15.8 %) - "diagnostic" TL with simultaneously invasive treatment (incl. surgical revision and percutaneous sclerotherapy). Treatment success rate and median time to treatment success were higher in group C than in group B, but without significant differences (64.3 % vs. 61.6 %, p = 0.710; six vs. five days, p = 0.065). Univariate and multivariate logistic regression analyses for group B confirmed drainage volume (> 500 ml/d) and Lipiodol extravasation as independent predictors of TL clinical failure (odds ratios [ORs] of 2.128 and 2.372 [p = 0.005 and p = 0.003, respectively]).

CONCLUSION

 TL is technically reliable, safe, and effective in treating PLL. When conservative treatment fails, TL can be regarded as the next treatment option.

KEY POINTS

  · TL is technically reliable, safe, and effective for treating PLL.. · When conservative treatment fails, TL can be regarded as the next treatment option.. · Drainage volume > 500 ml/day is an independent predictor of clinical failure after TL.. · Lipiodol extravasation is an independent predictor of clinical failure after TL..

CITATION FORMAT

· Pan F, Richter GM, Do TD et al. Treatment of Postoperative Lymphatic Leakage Applying Transpedal Lymphangiography - Experience in 355 Consecutive Patients. Fortschr Röntgenstr 2022; DOI: 10.1055/a-1717-2467.

Preliminary Exploration of Transpedal Lymphangiography With High-Dose Ethiodized Oil Application in the Treatment of Postoperative Chylothorax

Objective: To preliminarily explore the safety and effectiveness of transpedal lymphangiography (TL) with high-dose ethiodized oil application (&gt;20 ml) in the treatment of high-output postoperative chylothorax.

Methods: From 1 July 2020 to 1 July 2021, a total of 7 patients with high-flow postoperative chylothorax (&gt; 1,000 ml/d) were retrospectively reviewed in a single center. Clinical data, including surgery types, technical and treatment success of TL, and adverse events of TL, were collected and analyzed.

Results: Seven patients (5 cases of non-small cell lung cancer; 2 cases of esophageal carcinoma) with a median age of 62 years (range: 30–70 years) occurred postoperative chylothorax after tumor resection with mediastinal lymphadenectomy. All patients received conservative treatment including total parenteral nutrition and somatostatin administration for a median of 20 days (range: 15–31 days) that failed to cure the chylothorax, so TL was performed as a salvage. Before TL, the median daily chyle output was 1,500 ml/day (range: 1,100–2,000 ml/day). The technical success rate of TL was 100% (7/7), with the median volume of ethiodized oil of 27.6 ml (range: 21.2–30.0 ml) injected in TL. Ruptured thoracic duct was identified in 5 patients (5/7, 71%) in fluoroscopy and chest CT after TL. The treatment success rate of TL was 86% (6/7). In 6 patients, the thoracic drainage was removed after a median of 7 days (range: 4–13 days) from TL performance. No adverse event of TL was reported.

Conclusion: Transpedal lymphangiography with high-dose ethiodized oil application (&gt;20 ml) is a feasible, safe, and effective modality for the treatment of high-flow (&gt; 1,000 ml/day) postoperative chylothorax.

Giant Idiopathic Lymphocele 18 Years After Kidney Transplantation, Treated Using Lymphatic Embolization With Lipiodol: Report of a Rare Case

Kidney transplant is the best therapeutic option for patients with end-stage kidney disease. However, kidney transplant is not exempt from postoperative complications. One of the most frequent urological complications is lymphocele, which can appearin up to 20% of patients. Lymphocele most often appears during the first month after surgery. However, its appearance after the first yearis completely infrequent. Here, we report a case of a giant idiopathic lymphocele 18 years after kidney transplant and its resolution with lymphatic embolization.The patient, a 34-year-old man who received a deceased-donor kidney transplant in 2002, had presented with no complications until the lymphocele was diagnosed. The lymphocele presented as a voluminous organ-compressing mass. A percutaneous drainage was placed, and 3600 cm3 of lymphatic fluidwere drained.Afterthat, 800 cm3 continued to leak every day. An intranodal lymphography and lymphatic embolization with Lipiodol Ultra-Fluide (Guerbet Australia) were performed, owing to the high amount of leakage. At 50 days after embolization, an ultrasonograph showed no fluid collections, so the percutaneous catheter was removed. In most patients, the treatment ofthe lymphocele after kidney transplant is frequently conservative. However,for patients whose situation cannot be resolved spontaneously, there are few therapeutic choices. As described here, intranodal lymphatic embolization is a mini-invasive option, with a success rate of up to 80%, and should be offered as the first approach.

The lymphatics in kidney health and disease

The mammalian vascular system consists of two networks: the blood vascular system and the lymphatic vascular system. Throughout the body, the lymphatic system contributes to homeostatic mechanisms by draining extravasated interstitial fluid and facilitating the trafficking and activation of immune cells. In the kidney, lymphatic vessels exist mainly in the kidney cortex. In the medulla, the ascending vasa recta represent a hybrid lymphatic-like vessel that performs lymphatic-like roles in interstitial fluid reabsorption. Although the lymphatic network is mainly derived from the venous system, evidence supports the existence of lymphatic beds that are of non-venous origin. Following their development and maturation, lymphatic vessel density remains relatively stable; however, these vessels undergo dynamic functional changes to meet tissue demands. Additionally, new lymphatic growth, or lymphangiogenesis, can be induced by pathological conditions such as tissue injury, interstitial fluid overload, hyperglycaemia and inflammation. Lymphangiogenesis is also associated with conditions such as polycystic kidney disease, hypertension, ultrafiltration failure and transplant rejection. Although lymphangiogenesis has protective functions in clearing accumulated fluid and immune cells, the kidney lymphatics may also propagate an inflammatory feedback loop, exacerbating inflammation and fibrosis. Greater understanding of lymphatic biology, including the developmental origin and function of the lymphatics and their response to pathogenic stimuli, may aid the development of new therapeutic agents that target the lymphatic system.

Therapeutic Lymphangiography for Persistent Lymphatic Leak After Kidney Transplant: A Novel Technique

Lymphatic leakage is a common and well-described complication after kidney transplantation, occurring in up to 25% of patients. Accumulation of lymph is due to the surgical disruption of recipient lymphatic channels accompanying the external iliac vessels, complicated by lower extremity edema, wound breakdown, infection, and, if unresolved, graft loss due to extrinsic compression. In this report, we describe the novel use of diagnostic and therapeutic lymphangiography to successfully treat lymphatic leak after renal transplant that was resistant to drain placement, sclerotherapy, and laparoscopic peritoneal window creation. We also describe the methodology, indications, and contraindications and conclude that this technique is well-tolerated and offers a good option for complex lymph leaks that do not respond to conventional treatment. Further studies are required to compare its efficacy with other standard methods, including sclerotherapy and laparoscopic peritoneal fenestration, as the primary treatment modality.

Intranodal lymphangio-embolisation as treatment for lymphocele after kidney transplantation: A case report

Introduction and objectives:

The rate of symptomatic lymphoceles requiring intervention after renal transplantation is reported to be only 5.6%. Controversies prevail in the current literature regarding the management of symptomatic lymphoceles post renal transplantation, with no established algorithm. The creation of a peritoneal window, frequently performed laparoscopically, is deemed the gold standard for management. We herin report the case of a lymphocele post renal transplant treated minimally invasively with intranodal lymphangio-embolisation, with a review of the current literature of this uncommon procedure.

Methods:

This was a retrospective review of this patient’s electronic medical records.

Results:

We present a 43-year-old male with end-stage kidney disease secondary to chronic glomerulonephritis, having been on hemodialysis for seven years. He underwent a deceased donor dual kidney transplant, complicated postoperatively by renal vein thrombosis in one of the grafts, resulting in early graft nephrectomy as well as a distal ureterovesical leak requiring reimplantation. On re-implantation on postoperative day 16, he was noted to have a persistent high drain ouput with a normal drain fluid creatinine. A right intranodal lymphagiogram was performed, and this demonstrated an active lymph leak around the transplanted kidney. A 33% glue (N-butyl cyanoacrylate)-Lipodiol infusion was then injected at a rate of 0.2 mL/min intranodally under fluoroscopic guidance. The patient underwent another repeat embolisation five days later for a residual lymph leak with satisfactory results. Drain output subsequently decreased, and the drain was removed.

Conclusions:

This case suggests that intranodal lymphangiography and embolisation may not only be a diagnostic tool but can be considered as an effective, minimally invasive and safe method for the treatment of lymphoceles after kidney transplantation.

Treatment of lymphatic leakage after retroperitoneal tumor resection by lymphangiography and embolization: A case report

Lymphatic leakage is an infrequent but relatively serious complication after resection of retroperitoneal tumors. Although different approaches have been attempted in treatment of lymphatic leakage, none of them has been consistently effective. This study report on a female patient, aged 55-years with massive retroperitoneal tumor, with lymphangiography and embolization for resolution of lymphatic leakage after retroperitoneal tumor resection. Computed tomography revealed retroperitoneal cystadenoma. After the right ureteral stent was placed, the retroperitoneal tumor resection was performed, and after operation, the patient presented with lymphatic leakage unresponsive to several treatment measures. From the thirty-seventh postoperative day (POD37), the patient underwent lymphangiography and embolization, which resolved her lymphatic leakage. Lymphangiography is useful for detecting lymphatic leakage occurring after retroperitoneal tumor resection. Furthermore, lymphatic embolization is feasible, effective, and safe for managing leaks demonstrated on lymphangiography.

Lymphangiography with or without Embolization for the Treatment of Postoperative Chylous Ascites

BACKGROUND

Lymphatic interventions have recently been increasingly used for treating lymphatic leak of the abdomen and pelvis. This retrospective case study series and systematic review evaluated the efficacy and safety of lymphatic interventions for the treatment of postoperative lymphatic leak of the abdomen and pelvis.

METHODS

A total of 15 consecutive patients with postoperative lymphatic leak of the abdomen and pelvis treated with lymphatic interventions (i.e., diagnostic intranodal or pedal lymphangiography [LAG], i.e., potentially therapeutic or diagnostic LAG with intention to treat through embolization) at our institution were reviewed. The data of 72 patients from 13 relevant articles identified through a literature search of the MEDLINE/PubMed, EMBASE, and Cochrane databases were extracted.

RESULTS

The data of 87 patients (mean age, 59 [range, 24-84] years) were pooled. The technical success rate of LAG (intranodal approach, 78.2% [68/87]; pedal approach, 21.8% [19/87]) was 97.7% (85/87; 95% confidence interval [CI], 91.5-99.9%). Of the 85 patients in whom technical success of LAG was achieved, data on clinical success were available for 47 patients (55.3%). The clinical success rate of LAG was 68.1% (32/47; 95% CI, 53.8-79.7%). Of the 85 patients in whom technical success of LAG was achieved, 38 (44.7%) underwent embolization. The technical success rate of embolization was 97.4% (37/38; 95% CI, 85.3-99.9%). The clinical success rate of embolization was 70.3% (26/37; 95% CI, 54.1-82.6%). Major complications did not occur. The overall primary and secondary clinical success rates were 65.5% (57/87; 95% CI, 55.0-74.7%) and 78.2% (68/87; 95% CI, 68.3-85.6%), respectively.

CONCLUSIONS

Lymphatic interventions are safe and relatively effective adjunct to conservative therapy, with the primary and secondary clinical success rate of 65.5% and 78.2%, for postoperative lymphatic leak of the abdomen and pelvis.

Conventional Lymphangiography (CL) in the Management of Postoperative Lymphatic Leakage (PLL): A Systematic Review

BACKGROUND

 Postoperative lymphatic leakage (PLL) is usually managed by conservative and/or surgical treatments but these procedures can be challenging to perform and potentially clinically ineffective. Therefore, conventional lymphangiography (CL) has emerged as an important alternative. The aim of this review is to present the available outcome data on CL in the management of PLL.

METHOD

 A systematic literature search (PubMed) using the MeSH term "lymphangiography" was performed and the search was restricted to literature published between January 2007 and August 2019. Identification, screening, and assessment for eligibility and inclusion were conducted in accordance with PRISMA.

RESULTS

 From the initially obtained 1006 articles (identification), 28 articles with a total of 201 patients were finally included (inclusion). The methodological quality of all included articles corresponds to level 4 (Oxford Centre for Evidence-based Medicine - Levels of Evidence, March 2009). PLL occurs after oncological and non-oncological surgery in the form of chylothorax, chylous ascites, and cervical, thoracic, abdominal and peripheral lymph fistula and/or lymphocele. The technical success rate of CL is 75-100 %. Access for CL is transpedal (176 patients) or intranodal (25 patients). Lipiodol is used as the contrast material in all articles, with a maximum amount of 20 ml for transpedal CL and 30 ml for intranodal CL. The X-ray imaging modalities used for CL are fluoroscopy, radiography and/or CT. Two articles report CL-associated major complications and CL-associated morbidity and mortality. The PLL cure rate is 51-70 % for transpedal CL (time to PLL cure: 2-29 days) and 33-100 % for intranodal CL (time to PLL cure: 2-< 30 days). Bailout procedures in the case of clinically ineffective CL include a range of treatments.

CONCLUSION

 CL is feasible, safe, and effective in the management of PLL. Lipiodol as the contrast material is essential in CL because the highly viscous iodinated poppy-seed oil has not only diagnostic but therapeutic effects. Guidelines and randomized controlled trials are further steps towards defining the ultimate value of CL.

KEY POINTS

  · PLL is a difficult-to-treat and potentially life-threatening surgical complication.. · CL has emerged as an alternative to conservative/surgical treatment of PLL.. · CL is feasible, safe, and effective in the management of PLL. · Lipiodol-based CL can be regarded as a therapeutic procedure.. · Guidelines and randomized controlled trials are further important steps..

CITATION FORMAT

· Sommer CM, Pieper CC, Itkin M et al. Conventional Lymphangiography (CL) in the Management of Postoperative Lymphatic Leakage (PLL): A Systematic Review. Fortschr Röntgenstr 2020; 192: 1025 - 1035.

Back to the Future: Lipiodol in Lymphography-From Diagnostics to Theranostics

Lipiodol is an iodinated poppy seed oil first synthesized in 1901. Originally developed for therapeutic purposes, it has mainly become a diagnostic contrast medium since the 1920s. At the end of the 20th century, Lipiodol underwent a transition back to a therapeutic agent, as exemplified by its increasing use in lymphangiography and lymphatic interventions. Nowadays, indications for lymphangiography include chylothorax, chylous ascites, chyluria, and peripheral lymphatic fistula or lymphoceles. In these indications, Lipiodol alone has a therapeutic effect with clinical success in 51% to 100% of cases. The 2 main access sites to the lymphatic system for lymphangiography are cannulation of lymphatic vessels in the foot (transpedal) and direct puncture of (mainly inguinal) lymph nodes (transnodal). In case of failure of lymphangiography alone to occlude the leaking lymphatic vessel as well as in indications such as protein-losing enteropathy, postoperative hepatic lymphorrhea, or plastic bronchitis, lymphatic vessels can also be embolized directly by injecting a mixture of Lipiodol and surgical glues (most commonly in thoracic duct embolization). The aim of this article is to review the historical role of Lipiodol and the evolution of its clinical application in lymphangiography over time until the current state-of-the-art lymphatic imaging techniques and interventions.

Cardiofaciocutaneous syndrome with KRAS gene mutation presenting as chylopericardium

A 12-year-old female patient with cardiofaciocutaneous syndrome in the presence of a KRAS gene mutation had episodes of pericardial effusion on ultrasound, later confirmed to be chylopericardium, which resolved after a lymphangiography. We discussed herein the pathophysiological background of this rare case and the efficacy of lymphangiography in the treatment of chylopericardium.

Treatment of lymphatic leakage after retroperitoneal tumor resection by lymphangiography and embolization

•

This is a rate case of lymphatic leakage after the retroperitoneal giant tumor, which is rare in literature.

•

A variety of methods adopted for non-surgical treatment, including the relatively new lymphangiodochography and embolization.

•

Through the joint efforts of doctors and patients, patient was finally treated with conservative treatment and discharged.

Lymphatic leakage is an infrequent but relatively serious complication after resection of retroperitoneal tumors. Different approaches have been attempted in treatment of lymphatic leakage. However, to date none of them have been demonstrated consistently effective. We hereby report our preliminary experience with Lymphangiography and embolization for resolution of Lymphatic leakage after retroperitoneal tumor resection.

The patient, a 55-year-old woman with massive retroperitoneal tumor, Computed tomography (CT) revealed that retroperitoneal cystadenoma. After the right ureteral stent was placed, the retroperitoneal tumor resection was performed, postoperatively she presented with lymphatic leakage unresponsive to several treatment measures. From the thirty-seven postoperative day (POD37), the patient underwent Lymphangiography and embolization, which resolved her lymphatic leakage.

Lymphangiography is useful for detecting lymphatic leakage occurring after retroperitoneal tumor resection. Furthermore, lymphatic embolization is feasible, effective, and safe for managing leaks demonstrated on lymphangiography.