Groin lymphorrhea complicating revascularization involving the femoral vessels

Lymphatic leakage after pelvic lymphadenectomy for cervical cancer: a retrospective case-control study

BACKGROUND

The study aims to evaluate the clinical features and management of postoperative lymphatic leakage (PLL) in patients with cervical cancer who received pelvic lymphadenectomy.

METHODS

This retrospective study screened consecutive patients with cervical cancer (stage Ia2-IIb).

RESULTS

Among 3427 cases screened, 63 patients (1.8%) were diagnosed with PLL, which manifested as persistent abdominal drainage (42/63, 66.7%), chylous ascites (12/63, 19.0%) or vaginal drainage (9/63, 14.3%). Median time from surgery to onset of PLL was 6 days (range, 4-21 days). All cases resolved in a median 10 days (range, 3-56 days) after conservative treatment; although one case experienced recurrence of vaginal drainage after 26 days, this also resolved after conservative therapy. Multivariate analysis showed that two cycles of neoadjuvant chemotherapy (odds ratio [OR], 3.283; 95% confidence interval [95%CI], 1.289-8.360; P = 0.013), a decrease in hemoglobin level of ≥20 and < 30 g/L (OR, 6.175; 95%CI, 1.033-10.919; P = 0.046) or ≥ 30 g/L (OR, 8.467; 95%CI, 1.248-17.426; P = 0.029), and postoperative albumin level ≥ 30 and < 35 g/L (OR, 2.552; 95%CI, 1.112-5.857; P = 0.027) or < 30 g/L (OR, 5.517; 95%CI, 2.047-18.148; P = 0.012) were associated with PLL.

CONCLUSION

Neoadjuvant chemotherapy, postoperative anemia and postoperative hypoproteinemia are risk factors for PLL.

Combination of Lymph Node Embolization and Musculocutaneous Flap Operation for Managing Groin Lymphorrhea

Lymphorrhea complications are common following femoral exposure for endovascular procedures. In patients unresponsive to either non-operative or operative therapy, treatment can be complicated. A 86-year-old male patient experienced lymphorrhea after stent graft to treat an abdominal aortic aneurysm, and five operative debridement attempts failed. Intranodal lymphangiography revealed leakage points from two lymph nodes directly into the wound, which were resolved by lymph node embolization using glue. Because the wound was large, a pedicled anterolateral thigh flap (ALT) operation was indicated. Percutaneous lymph node embolization combined with ALT operation may be effective for patients with large wounds and high-flow lymphatic leaks.

Longitudinal versus transverse incision for common femoral artery exposure: a systematic review and meta-analysis

BACKGROUND

A longitudinal or a transverse incision is routinely used for common femoral artery (CFA) exposure. Some believe a transverse incision is associated with a lower incidence of postoperative complications. We performed a systematic review and meta-analysis to evaluate the risk of postoperative surgical site infection, lymphatic complications, wound dehiscence and haematoma formation when using a longitudinal or transverse incision for CFA exposure.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were adhered to. We searched various databases such as MEDLINE via PubMed and Embase for relevant studies from inception till 31 May 2020. Relevant search terms such as 'longitudinal', 'transverse', 'vertical', 'horizontal', 'femoral', 'incision' were used. We included both randomized controlled trials and case-controlled studies, and extracted data related to study characteristics and postoperative complications. We assessed risk of bias using the Cochrane risk of bias tool and the Newcastle-Ottawa scale. A random-effects meta-analysis was performed to obtain the pooled proportions and risk ratios (RR) for our study outcomes.

RESULTS

We included seven studies with a total of 5922 groin incisions. A longitudinal incision was associated with a significantly higher incidence of wound infection (RR 2.93, 95% confidence interval (CI) 1.12-7.70, P = 0.03) and wound dehiscence (RR 2.87, 95% CI 1.06-7.77, P = 0.04). The risk of lymphatic complications (RR 1.09, 95% CI 0.39-3.05, P = 0.87) and wound haematoma (RR 2.85, 95% CI 0.88-9.21, P = 0.08) were similar.

CONCLUSIONS

A longitudinal incision may be associated with a higher incidence of wound infection and wound dehiscence, as compared to using a transverse incision for CFA exposure.

Contemporary Review to Reduce Groin Surgical Site Infections in Vascular Surgery

Surgical site infection (SSIs) in lower extremity vascular procedures is a major contributor to patient morbidity and mortality. Despite previous advancements in preoperative and postoperative care, the surgical infection rate in vascular surgery remains high, particularly when groin incisions are involved. However, successfully targeting modifiable risk factors reduces the surgical site infection incidence in vascular surgery patients. We conducted an extensive literature review to evaluate the efficacy of various preventive strategies for groin surgical site infections. We discuss the role of preoperative showers, preoperative and postoperative antibiotics, collagen gentamicin implants, iodine impregnated drapes, types of skin incisions, negative pressure wound therapy, and prophylactic muscle flap transposition in preventing surgical site infection in the groin after vascular surgical procedures.

Lymphovenous anastomosis (LVA) for treatment of iatrogenic lymphocele in the thigh

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.

Transverse versus vertical groin incision for femoral artery approach

BACKGROUND

Access to the femoral vessels is necessary for a wide range of vascular procedures, including treatment of thromboembolic disease, arterial grafts (i.e. bifemoral aortic bypass or infrainguinal bypass), endovascular repair of abdominal aortic aneurysm (EVAR), thoracic endovascular aneurysm repair (TEVAR) and transcatheter aortic valve implantation (TAVI). The surgical technique used to access the femoral artery may be a factor in the occurrence of postoperative complications; this will be the focus of our review. We will compare the transverse surgical technique-a cut made parallel to the groin crease-versus the vertical groin incision surgical technique-classic technique: a surgical cut made across the groin crease-to access the femoral artery, in an attempt to determine which technique has the lower rate of complications, is safer and is more effective.

OBJECTIVES

To evaluate the efficacy and safety of transverse groin incision compared with vertical groin incision for accessing the femoral artery in endovascular surgical procedures and open surgery.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases, and the World Health Organization (WHO) International Clinical Trials Registry Platform and ClinicalTrials.gov to 17 February 2020. The review authors searched the IBECS database to 26 March 2020 and reference lists of relevant studies/papers.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-randomized trials (qRCTs) that compare transverse and vertical groin incision, during either endovascular or open surgery procedures.

DATA COLLECTION AND ANALYSIS

Two review authors (MVCRC, FCN) independently selected the studies, assessed risk of bias, extracted data, performed data analysis and graded the certainty of evidence according to GRADE.

MAIN RESULTS

We included one RCT and one qRCT in this review. These two studies had a combined total of 237 participants (283 groins). Infection of the surgical wound was the only outcome that was similar in both studies, and that could therefore be submitted to a combined analysis. Meta-analysis of the two studies showed low-certainty evidence that transverse groin incision resulted in a lower risk of surgical wound infection in the 10- to 28-day period following surgery (risk ratio [RR] 0.25, 95% confidence interval [CI] 0.08 to 0.76; 2 studies; 283 groin incisions). There was low heterogeneity between the studies. We downgraded the certainty of the evidence for surgical wound infection by one level due to serious limitations in the design (there was a high risk of bias in critical domains). The confidence interval for surgical wound infection is relatively wide, further indicating that the certainty of the effect estimate is low. This is likely due to the small number of studies and participants. We observed no evidence of a difference between the two surgical techniques for the other evaluated primary outcome 'lymphatic complications': lymphocele (RR 0.46, 95% CI 0.20 to 1.02; 1 study; 116 groins); and lymphorrhea (RR 2.77, 95% CI 0.92 to 8.34; 1 study; 116 groins). We downgraded the certainty of evidence for lymphatic complications by one level due to serious limitations in the design (there was a high risk of bias in critical domains); and by two further levels because of imprecision (small number of participants and only one study included). High-quality studies are needed to enable a comparison of the two surgical techniques with respect to other outcomes, such as infection of the vascular graft (endoprosthesis/prosthesis), prolonged hospitalization, reoperative surgery, death, neurological deficit (e.g. paresthesia), amputation, graft patency, and postoperative pain.

AUTHORS' CONCLUSIONS

In this systematic review, we found low-certainty evidence that performing transverse groin incision to access the femoral artery resulted in fewer surgical wound infections compared with performing vertical groin incision. We observed no evidence of a difference between the two surgical techniques for the other evaluated outcomes (lymphocele and lymphorrhea). Other outcomes were not evaluated in these studies. Limitations of this systematic review are, however, the small sample size, short clinical follow-up period and high risk of bias in critical domains. For this reason, the applicability of the results is limited.

Lymphatic Leaks of the Thigh and Inguinal Region: Combined Plastic Surgery Approaches for an Effective Treatment Algorithm

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.

Supermicrosurgical Lymphaticovenous Anastomosis as an Alternative Treatment Option for Patients with Lymphorrhea

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.

[Management of lymphatic fistulas in the groin from a surgeon's perspective]

BACKGROUND

The postoperative occurrence of lymph fistulas in the groin is a complication that should be taken seriously. These fistulas cause an increase in morbidity and can support local and ascending infections. The treatment of this complication ranges from conservative procedures, such as compression dressings and bed rest to operative treatment with detection of the fistulas and ligation, negative pressure wound therapy (NPWT) or even muscle flaps. This review provides an overview of current therapeutic modalities.

MATERIAL AND METHODS

On the basis of a current literature search via PubMed, we identified possible treatment options, which are described in this article.

RESULTS

The conservative treatment options presented still have an importance in treating groin fistulas. A selection of safe and effective interventional and operative treatments is presented.

CONCLUSION

If there are indications for an interventional or operative treatment a variety of safe and effective therapies are available, which can significantly reduce the length of hospital stay. The option of treatment using a muscle flap is of value as a last resort in the treatment of infected vascular prosthesis in the groin of Szilagyi type III and should be used when necessary.

Incidence and risk factors of groin lymphocele formation after venoarterial extracorporeal membrane oxygenation in cardiogenic shock patients

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.

Management of Femoral Lymphatic Complications Following Synthetic Lower Extremity Revascularization: Early and Late Results

Lymphatic complications following synthetic graft placement in the groin may be associated with prolonged drainage leading to the development of wound infection, which may involve the underlying prosthetic graft. To determine associated early and late mortality and morbidity and to develop guidelines for optimal management, the authors reviewed their department's recent experience with this problem.

From 1982 to 1996, 32 femoral lymphatic complications (29 lymphocutaneous fistulas and 3 lymphoceles) were treated in 26 patients (16 men and 10 women, mean age 68 years) who had undergone lower extremity revascularization utilizing synthetic graft material. Patients with clinical evidence of graft infection or those with lymphatic complications following autogenous reconstructions were excluded from analysis. Underlying grafts involved the aortofemoral segment in 63% (20/32), the femorofemoral segment in 16% (5/32), the femorodistal segment in 13% (4/32), and the axillofemoral segment in 9% (3/32). Presenting symptoms were wound drainage in 27 limbs (91%), a groin mass in 3 (9%), and both in 6% (2/32). Management consisted of surgical exploration and lymphatic ligation with or without sclerosis in 24 limbs (75%) and local measures only in 8 (25%). Mean late follow-up was 3.6 years (range 0.1-8.9 years), and one patient was lost to follow-up at 3.1 years.

There were no 30-day postoperative deaths. One patient died of pneumonia at 34 days after treatment. The median interval from treatment to wound resolution was 5 days for the entire series and was significantly shorter (2 days) for the surgically treated limbs than for those treated conservatively (38 days) (P=0.0001). The median interval from treatment to hospital discharge was also shorter for the surgically treated limbs (11 days) than for those treated conservatively (26 days) (P=0.025). There were no late recurrences, amputations, or graft infections. Cumulative 5-year survival for the entire series was 53%.

Surgical repair of groin lymphocutaneous fistulas and lymphoceles following synthetic graft placement is safe and durable. This approach yields significantly shorter intervals from treatment to wound resolution and requires a shorter postoperative hospitalization period than the conservative approach.

Transcatheter Aortic Valve Replacement

The role of transcatheter aortic valve replacement (TAVR) continues to evolve and expand at a rapid pace. The advanced age and frailty of many TAVR candidates often presents complex vascular access challenges when contemplating the exact route of valve delivery. As the indications and approved routes of delivery have evolved, so have the direct open vascular and percutaneous techniques paramount to success. We review the spectrum of access options that may be available for consideration during TAVR procedures and highlight the “pearls and pitfalls” of each technique. We additionally highlight reasons a technique may be preferred for a specific patient subset, as well as the concerns addressed by the anesthesiologist in approaching TAVR.

Navigation lymphatic supermicrosurgery for iatrogenic lymphorrhea: supermicrosurgical lymphaticolymphatic anastomosis and lymphaticovenular anastomosis under indocyanine green lymphography navigation

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.

Magnetic resonance lymphography at 3T: a promising noninvasive approach to characterise inguinal lymphatic vessel leakage

PURPOSE

To explore the feasibility of using 3T high-resolution MR lymphangiography to characterize inguinal lymphatic vessel leakage (LVL).

MATERIALS AND METHODS

Sixteen patients with known inguinal LVL underwent 3T MR lymphangiography and T(2)-weighted imaging. The presence or absence of inguinal LVL and the responsible lymphatic vessels were determined using the above imaging modalities and confirmed by surgical procedure. Afterwards, fifteen patients with recurring LVL following conservative treatment were referred to surgical intervention.

RESULTS

Specific inguinal LVL enhancement patterns and leaking lymphatic vessels were detected in 15 of 16 patients. Compared to the SNR of enhanced lymph nodes, that of the enhanced LVL was significantly greater (t = 7.149, p < 0.01), thereby making it possible to differentiate between LVL sites and enhancing inguinal lymph nodes. Furthermore, the steepest contrast enhancement curve slope of enhanced LVL was lower than that of enhanced lymph nodes (t = -2.860, p = 0.02). After MR diagnosis, 15 patients successfully underwent open exploration and ligation of the leaking lymphatic vessel. Clinical follow-up did not demonstrate recurrence of lymphatic fluid in the groin.

CONCLUSIONS

High-resolution MR lymphangiography combined with T(2)-weighted imaging is a promising approach to identifying specific features of lymphatic vessel leakage in the groin.

Polidocanol foam sclerotherapy is a new and effective treatment for post-operative lymphorrhea and lymphocele

BACKGROUND

The formation of post-operative lymphocele and lymphorrhea following lymph node surgery is a potentially serious complication. Until now there has been no consensus on the most effective treatment for these complications. Therefore, the aim of our clinical trial was to compare the use of polidocanol foam sclerotherapy with compression therapy to wound drainage, in the treatment of post-operative lymphoceles.

PATIENTS AND METHODS

Retrospectively we analysed the data of 33 consecutive surgical patients who had developed a post-operative lymphocele between 2004 and 2008. We offered all patients drainage with compression therapy or polidocanol foam sclerotherapy with 1-day compression to treat the post-operative lymphoceles.

RESULTS

Altogether, 12 patients were treated with polidocanol foam sclerotherapy and 21 patients were treated with drainage alone. Secretion volumes declined from initial 50-350 ml/day to 0-20 ml/day at the end of the therapy. Lymphorrhea resolved much quicker (P < 0.0001) in patients treated with polidocanol foam sclerotherapy (median 4 days, mean value 6.4 days) than in those treated with drainage (median 31 days, mean value 30.2 days). None of the patients developed a major complication.

CONCLUSION

Polidocanol foam sclerotherapy is an effective and well-tolerated new treatment for patients with post-operative lymphoceles.

Five Years' Experience of Transverse Groin Incision for Femoral Artery Access in Arterial Reconstructive Surgery: Parallel Observational Longitudinal Group Comparison Study

Vertical groin incisions (VGIs) have been used to access femoral vessels, but reports allude to wound complications. Our aim was to compare VGI with transverse groin incision (TGI) for femoral artery exposure. Over a 5-year interval, 196 patients with 284 femoral artery exposures for supra- and infrainguinal procedures were studied. Primary endpoints were surgical skin site wound infection, seroma, haematoma formation, and major lower limb amputation. Secondary endpoints were graft patency, wound paresthesias, and length of hospital stay. There were 160 TGIs and 124 VGIs. The demographics and risk factor profile were not statistically different between groups. Seroma developed in 4.4% of TGIs and 13.7% of VGIs ( p = .005). The complicated skin and soft tissue infection rate was five times greater with VGI ( p = .001). The VGI group had a significantly higher rate of major amputation ( p = .0005). Significantly higher graft failure rates were observed in the VGI group ( p = .011). No paresthesia was reported in any TGI wound. The mean hospital stay was also significantly shorter in the TGI group ( p = .006). The study data support and expound on the theory that an alternative incision to VGI offers lower short- and long-term morbidity. Our findings sustain the selection of the TGI in femoral artery surgery for both supra- and infrainguinal procedures without compromise of vessel exposure.

Treatment of a groin lymphatic fistula with negative pressure wound therapy

INTRODUCTION

Groin lymphatic fistulas are a troublesome finding after limb revascularization surgery. Its management represents a difficult task for the clinician.

REPORT

We report our experience in the treatment of such a condition with negative-pressure wound therapy (NPWT) in a 70-year-old man which benefited from extra-anatomic prosthetic axillofemoral bypass. After a week of treatment, the fistula dried up and closure was obtained with simple suture under local anaesthesia. Follow-up at 9 months showed stable coverage without any sign of leakage.

DISCUSSION

This study depicts NPWT as an effective non-invasive treatment in the management of groin lymphocutaneous fistula.

An Anatomical Study of the Gracilis Muscle and Its Application in Groin Wounds

The management of groin wounds is a common and challenging problem encountered in surgical practice. The purpose of this study is to examine the anatomic basis of the gracilis muscle with relation to this problem. Twelve cadaveric lower limbs were studied to examine both the extramuscular and intramuscular vasculature of the gracilis muscle. These underwent dissection and in 3 cases radiologic examination. The mean entry point of the dominant arterial pedicle was 9.4 cm, with mean length and width of the muscle recorded as 38.4 cm and 6.2 cm, respectively. Each gracilis muscle was then mobilized between the adductor longus and adductor magnus muscles on its dominant pedicle and transposed into the femoral triangle. In each case, the gracilis muscle mobilized easily on its dominant pedicle to adequately cover the groin. The gracilis muscle is a reliable muscle flap with a consistent blood supply, which can be transposed easily into the groin, based on its dominant pedicle, and offers adequate coverage of the femoral vessels.

Successful management of recalcitrant groin lymphorrhoea with the combination of intraoperative lymphatic mapping and muscle flap

Recalcitrant groin lymphorrhoea in high-risk patients remains a problem. In this report, a cardiac transplant patient with recalcitrant groin lymphorrhoea was successfully treated with a combination of intraoperative lymphatic mapping and sartorius muscle flap. We believe that the combined use of these two treatment options offers a more effective approach for surgical treatment of recalcitrant groin lymphorrhoea and should be considered when managing this difficult clinical problem, especially in high-risk patients.

Postoperative Lymphoceles: Detection with High-resolution MR Lymphangiography

Lymphoceles that do not resolve spontaneously or with treatment may be a major problem associated with a high degree of morbidity. Several imaging studies, including ultrasonography, computed tomography, magnetic resonance (MR) imaging, lymphography, lymphoscintigraphy, and intraoperative lymphatic mapping have been proposed to delineate lymphoceles before treatment. The present report describes the successful detection of three lymphoceles of the inguinal region with leaking lymphatic vessels by means of high-resolution MR lymphangiography.

Surgical Management of Groin Lymphatic Complications after Arterial Bypass Surgery

BACKGROUND

The authors undertook a retrospective study to define the incidence of groin wound lymphatic complications at their institution and to review their experience with treatment of the complications.

METHODS

Operating room records and patient databases of the two primary vascular surgeons at an academic teaching institution were reviewed retrospectively. Groin lymphatic complications were diagnosed by clinical presentation and confirmed with noninvasive imaging. Surgical management included percutaneous methods, ligation of leaking lymphatics, excision, and/or muscle flap coverage.

RESULTS

From June of 1989 to June of 2002, 538 patients had arterial revascularization procedures involving the groin. Twenty-seven patients with groin wound lymphatic complications were identified; seven of them had bilateral complications, for a total of 34 complication sites. Common comorbidities included hypertension, coronary artery disease, chronic renal insufficiency, and tobacco use. The majority (85 percent) had artificial material in the bypass graft, and 10 patients had undergone a previous operation at the same site. The mean time to identification of groin lymphatic complications after vascular surgery was 14 days. Common presentations included swelling (n = 16), drainage (n = 13), erythema (n = 4), and leg edema (n = 1). At presentation, 17 patients (63 percent) were receiving antibiotics and 21 (78 percent) were receiving anticoagulation or antiplatelet therapy. Of the 34 complication sites, 12 were managed with drainage or excision and 22 with muscle flap surgery, 10 of which failed less aggressive therapy. Muscle flaps included the gracilis (n = 19), sartorius (n = 1), rectus abdominis (n = 1), and rectus femoris muscles (n = 1). Operative cultures were positive in 23 of the 34 groin lymphatic complication sites. A biopsy specimen of a healed gracilis flap obtained at 1 year demonstrated notable lymphatic channels, possibly supporting theories that rotated muscle becomes a lymphatic conduit.

CONCLUSIONS

The authors found that muscle flap surgery provides single-intervention therapy for successful resolution of lymphoceles, with a low complication rate and fairly rapid recovery in a high-risk patient population. Flaps also salvage cases that have failed conservative therapy and provide hardy coverage for a wound bed that is often infected.

Femoral incision morbidity following endovascular aortic aneurysm repair

Currently available aortic stent-grafts require bilateral femoral incisions for device deployment. The incidence of morbidity (infection, lymphatic complications, breakdown) of vertical, infrainguinal incisions used in endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAAs) was assessed, and the natural history of asymptomatic groin fluid collections following such procedures was determined. Between June 1999 and February 2001, 77 consecutive patients underwent EVAR for AAAs utilizing bilateral vertical femoral incisions. Fifty-nine (77%) bifurcated stent-grafts (BSGs), and 18 (23%) aortouniiliac (AUI) devices, with femorofemoral bypass were performed. Patients returned at 2 weeks, 1 month, and 6 months for physical examination, and 1 month and 6 months for abdominal and pelvic computed tomography (CT) scans. The presence of fluid collections was determined from the dictation report of the attending radiologist. Data are reported as (n) mean +/-SE. Patient characteristics were compared using Fisher's exact test; p<0.05 considered significant. There were 72 males and 5 females, age 75 +/-6.4 years and aneurysm size (77) 5.6 +/-0.8 cm. There were no cases of wound breakdown or lymph fistula. Wound infections occurred in 3/150 incisions (2%), 2/34 AUI incisions (6%), and 1/116 BSG incisions (0.86%). There was no statistical difference (p=0.13) between graft types (BSG vs AUI). All infections were diagnosed clinically before the 1-month CT scan, treated without operative intervention or hospitalization, and resolved. There was a significant decrease in the BSG group and overall in asymptomatic wound fluid collections from 1 to 6 months postoperatively. At 1 and 6 months, respectively, the BSG group had 17 (14.6%) and 3 (2.6%) fluid collections out of 116 incisions (p=0.003); the AUI group had 6 (17.6%) and 1 (2.9%) fluid collection(s) out of 34 incisions (p=0.13); and overall 23 (15.3%) and 4 (2.6%) out of 150 incisions (p=0.004). The present study demonstrates that bilateral vertical femoral incisions used in EVAR have a wound infection rate of 2.0%. Infections are usually detected and treated clinically and empirically without the need for hospitalization or surgery. Asymptomatic groin wound fluid collections resolve significantly within 6 months without intervention. Therefore, surgical femoral artery exposure adds little morbidity to the endovascular repair of abdominal aortic aneurysms.

Does fibrin glue reduce complications after femoral artery surgery? A randomised trial

OBJECTIVES

to determine whether application of fibrin glue before closure of inguinal wounds reduces the incidence of lymphatic complications.

DESIGN

we a prospective randomised trial.

MATERIALS AND METHODS

224 consecutive patients were enrolled. The wounds were randomly assigned to standard closure (group A, n = 134) or closure with application of fibrin glue (group B, n = 132). The incidence of local lymphatic and non-lymphatic complications, the amount of lymphatic fluid collected, and the time to drain removal were compared in the groups.

RESULTS

the incidence of lymphatic complications was 19% in group A and 10% in group B (p = 0.027). The average drain output and the time to drain removal did not differ in the two groups. The total incidence of non-lymphatic local complications was 10% and did not differ in the two groups.

CONCLUSIONS

fibrin glue application is associated with a significant reduction in lymphatic complications.

Successful treatment of 19 consecutive groin lymphoceles with the assistance of intraoperative lymphatic mapping

Postoperative groin lymphoceles that fail to resolve spontaneously or with interventional therapy present a formidable problem that is associated with a high degree of morbidity. Numerous interventional methods and operative techniques have been described to treat these fluid collections, yet recurrence rates remain high. The use of lymphatic mapping has gained widespread use in the treatment of cutaneous malignancies and breast cancer and has been proven effective in delineating the course of lymphatic channels. We present here a series of 17 consecutive patients with 19 problematic groin lymphoceles who were treated with the assistance of intraoperative lymphatic mapping using isosulfan blue dye. To date there have been no recurrences and minimal morbidity associated with the technique and prescribed postoperative treatment regimen.

Intraoperative lymphatic mapping to treat groin lymphorrhea complicating an elective medial thigh lift

Groin lymphoceles and lymphorrhea are a rare complication of medial thigh lift procedures. The author describes a case in which a very thin patient developed groin lymphorrhea after an uncomplicated medial thigh lift procedure. Initial treatment interventions, including edema control and the placement of a drain with surgical exploration, failed to control the lymphatic leak. Additionally, the onset of an infection and abscess formation complicated the treatment efforts. Using techniques well established in treating cutaneous malignancies, the lymphocele was treated successfully by identifying three separately damaged lymphatic channels with the use of intraoperative lymphatic mapping with blue dye. No drains were needed and the immediate cessation of lymph flow was noted. Using this novel adaptation of a well-known technique, the groin lymphocele was able to be repaired quickly and effectively with minimal morbidity and no evidence of recurrence to date.

Reduction of groin lymphatic complications by application of fibrin glue: preliminary results of a randomized study

Lymphoceles and lymph fistulas are common complications after exposure of the common femoral artery in the Scarpa triangle because of operative transsection of overlying lymphatics. The purpose of this prospective randomized study was to determine the incidence of groin lymphatic complications and to assess the impact of routine application of fibrin glue on lymphatic structures and subcutaneous tissue prior to closure. All patients undergoing exposure of the common femoral artery in the Scarpa triangle were included in this study. They were divided into two groups according to closure technique. In group A, closure was performed without fibrin glue. In Group B, fibrin glue was applied to lymphatic structures prior to closure. The efficacy of fibrin glue application was estimated on the basis of two criteria: incidence of local complications and amount of lymphatic fluid in the Redon drain. The preliminary findings suggest that application of fibrin glue leads to a significant reduction in the incidence of lymphatic complications after femoral artery exposure in the Scarpa triangle.

Lymphoscintigraphy in the diagnosis of lymphatic leak after surgical repair of femoral artery injury

PURPOSE

Technetium-99m-labeled sulfur colloid lymphoscintigraphy is useful to evaluate lower extremity lymphatic circulation in cases of possible lymphedema and to reveal abnormal lymphatic collections. Groin lymphatic fistulas and lymphoceles are known complications of peripheral vascular surgical procedures. The authors describe a patient with ascites that developed into right lower extremity swelling after surgical repair of a femoral artery injury. Even after surgical ligation of multiple lymphatic channels, the patient continued to have lymphorrhea. It was unclear whether this was attributable to a persistent lymphatic leak or an ascitic leak from a postsurgical defect resulting in an abnormal connection with the peritoneal cavity.

METHODS

Lymphoscintigraphy of the lower extremities was performed using Tc-99m sulfur colloid. Images were obtained at several intervals after injection of the radiotracer. Images were also acquired after the wound packing was removed.

RESULTS

The images revealed an accumulation of radiotracer in the right groin, confirming the lower extremity lymphatic origin of the collection.

CONCLUSIONS

Lymphoscintigraphy is useful to evaluate the origin of serous collections in the groin, a region in which lymphatic complications of vascular surgery are not uncommon.

The use of subatmospheric pressure dressing therapy to close lymphocutaneous fistulas of the groin

Groin lymphorrhea is an uncommon but serious complication of vascular and cardiac surgery as well as interventional procedures that cannulate the femoral vessels. Treatment options are somewhat controversial. For lymphocutaneous fistulas, a commonly used current modality is early surgical ligation with the assistance of blue-dye staining of the lymphatic anatomy. The purpose of this case series is to give the first description of a new, less invasive, approach using subatmospheric pressure dressing therapy for the treatment of the challenging problem of lymphocutaneous fistulas of the groin.

The value of the oblique groin incision for femoral artery access during endovascular procedures

Groin incisions for access to femoral vessels are typically made in a vertical fashion extending across the groin crease. Significant morbidity can be associated with these incisions, including lymphoceles, lymph fistulae and infections, as documented in the infrainguinal revascularization literature. We have adopted an oblique groin incision for femoral artery access during endovascular graft reconstruction of the aorta because of the potential for reduced wound morbidity. In this study we report our experience with this technique and compare it with the existing literature to determine its usefulness. From June 1998 to May 1999, 98 consecutive patients received endovascular exclusion of aortic aneurysms at The Mount Sinai Medical Center, New York. Patients were treated with aortoaortic (24), aortouniiliac with femorofemoral crossover bypass (41), or bifurcated endografts (33) and were prospectively studied for wound complications. Aortoaortic procedures required one inguinal incision whereas aortouniiliac with femorofemoral crossover bypass and bifurcated procedures employed bilateral inguinal wounds. Wound complications were defined as cellulitis, subcutaneous purulence, femorofemoral graft infection, lymphocele, or lymphocutaneous fistulae. The oblique groin incision allows adequate exposure to the femoral arteries and is associated with low wound morbidity. We suggest that this approach may be the preferred technique for access to femoral arteries during endovascular procedures, and should be considered for infrainguinal arterial reconstructions.

[Diagnosis of non-hernia groin masses]

Hernia is the most frequent etiology of a groin mass except in 1 or 2% of cases. Seven cases of atypical groin masses were reported. The different etiologies of the masses were reminded, with useful investigative procedures. A precise history and a detailed physical examination are necessary to determine the most valuable exam in each patient.

Thigh isosulfan blue injection in the treatment of postoperative lymphatic complications

Postoperative lymphatic complications after infrainguinal revascularization are troublesome and potentially serious complications. Vital dye injection into the web spaces of the foot has been recommended as a simple and reliable method to identify lymphatic channel disruption before groin exploration. Such distal injections, however, are not always successful. We describe a modified technique using a proximal thigh injection with isosulfan blue, which is faster and more useful than the distal web space method.

A novel therapy for lymphedema complicated by lymphorrhea

Lymphorrhea is a rarely described complication of chronic lymphedema, in which the disrupted flow through diseased lymphatic channels gives rise to the external drainage of lymph, often heralded by the presence of an enlarging lymphocele. This report documents the applicability of the Reid sleeve, a novel, conservative form of therapy, in an unusually severe and protracted example of lymphorrhea.

A percutaneous technique for venovenous bypass in orthotopic cadaver liver transplantation and comparison with the open technique

Venovenous bypass minimizes the hemodynamic alterations during the anhepatic phase of liver transplantation. A new technique for the percutaneous placement of the bypass cannulae is described and compared to the cut-down ("open") technique. The records of 81 patients who underwent 94 liver transplants between August 1991 and April 1994 were reviewed for indications for transplant, United Network for Organ Sharing status, mean age, body surface area, bypass technique and time, flow rates, cardiac output, mean arterial pressure and central venous pressure during bypass, the development of deep venous thrombophlebitis, and lymphoceles. Femoral flow rates were higher in the open group (2054 +/- 74 mL/min), compared with the percutaneous group (1726 +/- 74 mL/min) (p = 0.003). Total flow rates in the open (2238 +/- 58 mL/min) and percutaneous (2197 +/- 67 mL/min) groups were not different. Maximum cardiac outputs (L/ min) were higher in the open (10.1 +/- 0.6) versus percutaneous group (7.0 +/- 0.5) (p < 0.0002). Similarly, minimum cardiac outputs (L/min) were higher in the open (8.9 +/- 0.7) versus percutaneous group (5.8 +/- 0.5) (p = 0.003). Other hemodynamic parameters (mean arterial pressure, central venous pressure) were not different between groups. Venous thrombosis occurred in 1/50 (2.0%) and 4/34 (11.8%) patients in the open and percutaneous groups, respectively (p = 0.153). Nineteen lymphoceles occurred in 102 (18.6%) at-risk sites in the open group, whereas no lymphoceles occurred in 66 at-risk sites in the percutaneous group (p < 0.001). Groin lymphoceles occurred in 7/50 (14%) and 0/34 at-risk sites in the open and percutaneous groups, respectively (p = 0.039). Axillary lymphoceles occurred in 12/52 (23.1%) and 0/32 at-risk sites in the open and percutaneous groups, respectively (p = 0.0031). Operative repair of a lymphocele was required in 11/16 (69%) patients. The percutaneous placement of catheters for venovenous bypass has the advantage of comparable flow rates with satisfactory hemodynamics without the lymphatic complications of the cut-down technique.

Prospective study of wound complications in continuous infrainguinal incisions after lower limb arterial reconstruction: incidence, risk factors, and cost

BACKGROUND

Wound complications after lower extremity arterial reconstruction can range from a minor lymphatic leak that causes minimal disability to a severe infection that jeopardizes the limb and life of the affected patient. This study was designed to define more clearly the incidence, severity, and the cost of these complications.

METHODS

During a 1-year period the infrainguinal incisions of all patients undergoing lower limb arterial reconstruction were evaluated prospectively. One hundred fifty-six infrainguinal incisions were monitored serially for the presence of infection, hematoma, seroma, serous leak, necrosis, or wound dehiscence. The need for additional treatment or services related to these complications and the cost of these services were determined.

RESULTS

Complications occurred in 10% of 77 infrainguinal incisions that were isolated to the groin (groin incisions) e.g., after aortobifemoral bypass, femoral endarterectomy). In only one of these patients was significant cost related to treatment of a complication. Complications occurred in 44% of 79 incisions used for femoral popliteal/tibial and pedal bypasses (distal incisions). In this latter group independent predictors of any complication were age (p=0.02) and obesity (p=0.05); predictors of in-hospital infection were preoperative evidence of venous stasis (p=0.01) and preoperative infection in the same extremity (p=0.08). Fifteen distal wound complications provided additional expense related to reoperation, extended hospitalization or rehospitalization, and rehabilitation or visiting nurse services, with a mean cost per patient undergoing reconstruction of $688.

CONCLUSIONS

After lower limb arterial reconstruction, infrainguinal wound complications in isolated groin incisions produce minimal morbidity and cost, whereas complications in incisions after distal bypass are both frequent and associated with significant additional expense.