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Purwono G, Lee YT, Chua JH, Loh AH. Systematic Lymphatic Repair for Reduction of Postoperative Lymphatic Leak Following Neuroblastoma Resection. J Pediatr Surg 2024; 59:1591-1599. [PMID: 38493026 DOI: 10.1016/j.jpedsurg.2024.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 02/12/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND Gross total resection of neuroblastoma is associated with lymphatic leaks that can delay postoperative resumption of treatment. To prevent postoperative lymphatic leak, we introduced systematic lymphatic repair (SLR), which involved oversewing the entire edge of the disrupted lymphatic plane after neuroblastoma resection. We sought to study the impact of SLR on postoperative lymphatic leak and time to return to treatment. METHODS We reviewed 60 neuroblastoma patients who underwent gross total resection at KK Women's and Children's Hospital. Patient, disease, and operative factors were correlated with surgical drainage, treatment delay and length of stay (LOS). Among patients with sufficient records, the interaction between variables associated with drainage, delay and LOS outcomes were compared in 14 patients who had SLR versus 35 historical controls who had targeted lymphatic repair (TLR). RESULTS Postoperative drain duration and volume were significantly higher in tumors with ≥2 image-derived risk factors (IDRFs, P = 0.005 and P = 0.013, respectively) or vessel encasement (P = 0.031 and P = 0.024, respectively). Longer LOS was significantly associated with ≥2 IDRFs (P = 0.006). All forms of suture repair of lymphatics and use of Tachosil™ were associated with significantly longer postoperative drain duration (P < 0.05); the former was also associated with significantly higher total drain volume (P < 0.05) - indicating appropriate use of these adjuncts in patients at risk of chyle leak. In patients who had suture repair of lymphatics, SLR was significantly associated with reduced postoperative interval to chemotherapy resumption (P = 0.014, two-way ANOVA). CONCLUSION A systematic approach to repair of lymphatic channels following neuroblastoma resection can significantly reduce time to postoperative resumption of treatment. TYPE OF STUDY Clinical Research. LEVEL OF EVIDENCE III.
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Affiliation(s)
| | - York Tien Lee
- Duke-NUS Medical School, Singapore; Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore; VIVA-KKH Paediatric Brain and Solid Tumour Programme, KKH Children's Blood and Cancer Centre, KK Women's and Children's Hospital, Singapore
| | - Joyce Hy Chua
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore
| | - Amos Hp Loh
- Duke-NUS Medical School, Singapore; Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore; VIVA-KKH Paediatric Brain and Solid Tumour Programme, KKH Children's Blood and Cancer Centre, KK Women's and Children's Hospital, Singapore.
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des Bordes U, Hoang T, Dale BS, Sharma AK. Sclerotherapy of the Post renal Transplant Lymphoceles: A Meta-Analysis. Transplant Proc 2024; 56:316-321. [PMID: 38368131 DOI: 10.1016/j.transproceed.2024.01.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 01/16/2024] [Indexed: 02/19/2024]
Abstract
PURPOSE This study evaluated the effectiveness of sclerotherapy in treating lymphoceles after kidney transplantation, focusing on factors such as recurrence rates and procedural success. MATERIALS AND METHODS Retrospective studies using sclerotherapy as the only form of treatment for postrenal transplant lymphoceles were included. All studies used percutaneous transcatheter sclerotherapy as treatment, and the success rate of the intervention was recorded. Sixty-one references were obtained by manually searching the MEDLINE (n = 20), Embase (n = 41), and Cochrane Library databases (n = 0) for retrospective research studies that included the keywords "sclerotherapy post renal transplant lymphoceles." After removing 3 duplicates, 50 of the remaining articles were excluded after the screening, and the remaining studies were extracted for demographic data and our primary outcome of the success rate of sclerotherapy. RESULTS A descriptive analysis of the outcomes and complication rates associated with sclerotherapy interventions for lymphoceles is provided. A high degree of variation across the different studies was observed. According to the Kruskal-Wallis test, there was no correlation between the sclerosant used and the sclerotherapy complication rate (P = .472) or the success rate (P = .591). There was also no correlation between the gender of the patient and the success rate; however, there was a significant difference in the complication rate by gender (P < .005). CONCLUSIONS In conclusion, different sclerosant products have been used for therapy with no consensus on the most efficacious product because the success rate has been variable. In addition, the gender of the patient may influence the complication rates associated with sclerotherapy for lymphoceles in patients post-kidney transplant.
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Affiliation(s)
- Ursula des Bordes
- Department of Internal Medicine, University of Rochester, Rochester, New York
| | | | - Benjamin S Dale
- Department of Surgery, University of Rochester, Rochester, New York
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Pieper CC. Back to the Future II-A Comprehensive Update on the Rapidly Evolving Field of Lymphatic Imaging and Interventions. Invest Radiol 2023; 58:610-640. [PMID: 37058335 DOI: 10.1097/rli.0000000000000966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
ABSTRACT Lymphatic imaging and interventional therapies of disorders affecting the lymphatic vascular system have evolved rapidly in recent years. Although x-ray lymphangiography had been all but replaced by the advent of cross-sectional imaging and the scientific focus shifted to lymph node imaging (eg, for detection of metastatic disease), interest in lymph vessel imaging was rekindled by the introduction of lymphatic interventional treatments in the late 1990s. Although x-ray lymphangiography is still the mainstay imaging technique to guide interventional procedures, several other, often less invasive, techniques have been developed more recently to evaluate the lymphatic vascular system and associated pathologies. Especially the introduction of magnetic resonance, and even more recently computed tomography, lymphangiography with water-soluble iodinated contrast agent has furthered our understanding of complex pathophysiological backgrounds of lymphatic diseases. This has led to an improvement of treatment approaches, especially of nontraumatic disorders caused by lymphatic flow abnormalities including plastic bronchitis, protein-losing enteropathy, and nontraumatic chylolymphatic leakages. The therapeutic armamentarium has also constantly grown and diversified in recent years with the introduction of more complex catheter-based and interstitial embolization techniques, lymph vessel stenting, lymphovenous anastomoses, as well as (targeted) medical treatment options. The aim of this article is to review the relevant spectrum of lymphatic disorders with currently available radiological imaging and interventional techniques, as well as the application of these methods in specific, individual clinical situations.
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Affiliation(s)
- Claus C Pieper
- From the Division for Minimally Invasive Lymphatic Therapy, Department of Diagnostic and Interventional Radiology, University Hospital Bonn; and Center for Rare Congenital Lymphatic Diseases, Center of Rare Diseases Bonn, Bonn, Germany
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Liu HT, Liu CA, Wang HK, Liu CS, Shen SH. Minimal invasive treatment for post-liver and renal transplant lymphatic leaks. Clin Transplant 2022; 36:e14691. [PMID: 35485283 DOI: 10.1111/ctr.14691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 04/13/2022] [Accepted: 04/23/2022] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Hsien-Tzu Liu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Radiology, Shuang-Ho Hospital, Taiwan, New Taipei City, Taiwan.,National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chien-An Liu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.,National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hsin-Kai Wang
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.,National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chin-Su Liu
- National Yang Ming Chiao Tung University, Taipei, Taiwan.,Division of Transplantation Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shu-Huei Shen
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan.,National Yang Ming Chiao Tung University, Taipei, Taiwan
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Isiktas Sayilar E, Ersoy A, Ayar Y, Aydin MF, Sahin AB, Coskun B, Kaygisiz O, Yildiz A, Kordan Y, Vuruskan H. Factors Influencing Lymphocele Development After Kidney Transplant: Single Center Experience. EXP CLIN TRANSPLANT 2022; 21:116-122. [PMID: 31250740 DOI: 10.6002/ect.2018.0293] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Lymphocele is a well-known postoperative surgical complication after kidney transplant. In this study, our aim was to analyze incidence, risk factors, and outcomes of posttransplant lymphocele in a large cohort. MATERIALS AND METHODS This observational study included 395 consecutive patients (219 males and 176 females) who underwent kidney transplant procedures from 183 living and 212 deceased donors in our center between January 2007 and 2014. A lymphocele was diagnosed with ultrasonography. RESULTS The incidence of lymphoceles in our cohort was 31.9% (n = 126). There were no significant dif-ferences with regard to body mass indexes, age of donors, deceased donor ratios, acute rejection episodes, and history of abdominal surgery between those with and without lymphoceles. The pre-transplant serum albumin levels (3.29 ± 0.67 vs 3.48 ± 0.69 g/dL; P = .009) in the lymphocele group and diabetes mellitus ratios (15.9% vs 4.5%; P < .001) in the nonlymphocele group were lower than levels shown in the other group. The lymphocele ratio in patients who received cyclosporine was higher than that shown in patients who did not received it (37.5% vs. 27.4%; P = .032). There was no difference in lymphocele incidence between patients who were taking and those who were not taking mammalian target of rapamycin inhibitors, mycophenolate mofetil, or mycophenolate sodium. In regression analysis, presence of diabetes mellitus, transplant from deceased donors, older age of donors, and lower albumin levels were independent risk factors for posttransplant lymphocele occurrence. CONCLUSIONS Posttransplant lymphocele was a relatively common surgical complication in our cohort. We concluded that diabetes mellitus, use of kidneys from deceased donors, older donor age, and hypoalbuminemia were independent risk factors for lymphocele development.
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Affiliation(s)
- Emel Isiktas Sayilar
- From the Department of Nephrology, Uludag University Faculty of Medicine, Bursa, Turkey
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Balderi A, Peano E, Bongiovanni S, Castiglione D. Real-Time Fluoroscopic Needle Guidance Software Application for Cisterna Chyli Puncture in Lymphatic Interventions by the use of Tailored Route: Proof of Concept. Cardiovasc Intervent Radiol 2021; 45:395-397. [PMID: 34853872 DOI: 10.1007/s00270-021-03013-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/21/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Alberto Balderi
- Azienda Ospedaliera S. Croce E Carle, Servizio di Radiologia Interventistica, Cuneo, Italy
| | - Enrico Peano
- Azienda Ospedaliera S. Croce E Carle, Servizio di Radiologia Interventistica, Cuneo, Italy
| | - Simone Bongiovanni
- Azienda Ospedaliera S. Croce E Carle, Servizio di Radiologia Interventistica, Cuneo, Italy
| | - Davide Castiglione
- Azienda Ospedaliera S. Croce E Carle, Servizio di Radiologia Interventistica, Cuneo, Italy. .,AOUP Paolo Giaccone, Dipartimento di Biomedicina, Neuroscienze e Diagnostica Avanzata (BiND), University of Palermo, Via del Vespro 129, 90123, Palermo, Italy. .,Radiology I Unit, Department of Medical Surgical Sciences and Advanced Technologies "GF Ingrassia", University Hospital "Policlinico-Vittorio Emanuele", 95123, Catania, Italy.
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Donnan MD, Kenig-Kozlovsky Y, Quaggin SE. The lymphatics in kidney health and disease. Nat Rev Nephrol 2021; 17:655-675. [PMID: 34158633 DOI: 10.1038/s41581-021-00438-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2021] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Michael D Donnan
- Feinberg Cardiovascular & Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of Nephrology & Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Susan E Quaggin
- Feinberg Cardiovascular & Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Division of Nephrology & Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Risk Factors, Diagnosis, and Treatment of Lymphocele After Renal Transplantation: A Retrospective Study. Transplant Proc 2021; 53:1040-1047. [PMID: 33573817 DOI: 10.1016/j.transproceed.2021.01.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 11/23/2020] [Accepted: 01/08/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Despite recent advances, lymphoceles are the most frequent complications following renal transplantation (RT), with an incidence of 0.6% to 51%. In this study, we present risk factors, treatments, and outcomes for lymphoceles after RT at our center. MATERIAL AND METHODS Since January 2018, 461 RTs were performed at our center. Nine recipients were excluded. The remaining 452 RTs were analyzed retrospectively. Recipients were divided into 2 groups: a lymphocele group (n = 29) and a nonlymphocele group (n = 423). Lymphoceles were diagnosed by ultrasound. Statistical analyses were made using the SPSS 15 software program. RESULTS Twenty-nine (6.4%) of the 452 recipients developed lymphoceles. Seven of these 29 (24.1%) recipients were asymptomatic. The most common symptom was hydronephrosis (34.4%). Percutaneous drainage was performed in 21 recipients; sclerotherapy with percutaneous drainage was used in the remaining 8. In 5 (17.2%) recipients, there was a recurrence of lymphoceles. There were significant differences with respect to age (50-65 years; P = .016), use of a drainage catheter (P = .044), and polycystic kidney diseases (P = .049). CONCLUSION Lymphoceles can be treated successfully using the percutaneous drainage technique alone or in combination with povidone iodine. Drainage use, polycystic kidney disease, and age (50-65 years) were established as risk factors for lymphocele development.
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Treatment of symptomatic postoperative pelvic lymphoceles: A systematic review. Eur J Radiol 2020; 134:109459. [PMID: 33302026 DOI: 10.1016/j.ejrad.2020.109459] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 11/10/2020] [Accepted: 11/30/2020] [Indexed: 01/22/2023]
Abstract
PURPOSE A broad range of therapeutic options exists for symptomatic postoperative lymphoceles. However, no consensus exists on what is the optimal therapy. In this study, we aimed to compare the efficacy of currently available radiologic interventions in terms of number of successful interventions, number of recurrences, and number of complications. METHODS A systematic review was conducted with a pre-defined search strategy for PubMed, EMBASE, and Cochrane databases from inception until September 2019. Quality assessment was performed using the 'Risk Of Bias In Non-randomized Studies - of Interventions' tool. Statistical heterogeneity was assessed using the I2 and χ2 test and a meta-analysis was considered for studies reporting on multiple interventions. RESULTS 37 eligible studies including 732 lymphoceles were identified. Proportions of successful interventions for percutaneous fine needle aspiration, percutaneous catheter drainage, percutaneous catheter drainage with delayed or instantaneous addition of sclerotherapy, and embolization were as follows: 0.341 (95% confidence interval [CI]: 0.185-0.542), 0.612 (95% CI: 0.490-0.722), 0.890 (95% CI: 0.781-0.948), 0.872 (95% CI: 0.710-0.949), 0.922 (95% CI: 0.731-0.981). Random-effects meta-analysis of seven studies revealed a pooled relative risk for percutaneous catheter drainage with delayed addition of sclerotherapy of 1.57 (95% CI: 1.17-2.10) when compared to percutaneous catheter drainage alone. The risk of bias in this study was severe. CONCLUSIONS This systematic review demonstrates that the success rates of percutaneous catheter drainage with sclerotherapy are more favorable when compared to percutaneous catheter drainage alone in the treatment of postoperative pelvic lymphoceles. Overall, percutaneous catheter drainage with delayed addition of sclerotherapy, and embolization showed the best outcomes.
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Pan F, Loos M, Do TD, Richter GM, Kauczor HU, Hackert T, Sommer CM. The roles of iodized oil-based lymphangiography and post-lymphangiographic computed tomography for specific lymphatic intervention planning in patients with postoperative lymphatic fistula: a literature review and case series. CVIR Endovasc 2020; 3:79. [PMID: 33085018 PMCID: PMC7578215 DOI: 10.1186/s42155-020-00146-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/03/2020] [Indexed: 01/30/2023] Open
Abstract
In the management of patients with postoperative lymphatic fistula (LF) in different locations, iodized oil-based lymphangiography (LAG) from trans-pedal or intranodal route is an established diagnostic approach with the potential to plan further interventional treatments. However, specific lymphatic interventions are indicated depending on different locations and morphologies of the LF. After a systematic literature review, four types of interventions can be considered, including direct leakage embolization/sclerotherapy (DLE/DLS), percutaneous afferent lymphatic vessel embolization (ALVE), percutaneous afferent lymphatic vessels disruption/sclerotherapy (ALVD/ALVS), and trans-afferent nodal embolization (TNE). In the iodized oil-based LAG, three potential lymphatic targets including confined leakage, definite afferent LVs, and definite closest afferent LNs should be comprehensively assessed. For optimal prospective treatment planning for LF, iodized oil-based post-lymphangiographic computed tomography (post-LAG CT) is a useful complement to the conventional iodized oil-based LAG, which can be performed easily after LAG. This review article summarized the current evidence of the specific lymphatic interventions in patients with postoperative LF and explored the potential benefits of post-LAG CT in the intervention planning from a case series.
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Affiliation(s)
- F Pan
- Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, INF 110, 69120, Heidelberg, Germany.,Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - M Loos
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - T D Do
- Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, INF 110, 69120, Heidelberg, Germany
| | - G M Richter
- Clinic for Diagnostic and Interventional Radiology, Stuttgart Clinics, Katharinenhospital, Kriegsbergstrasse 60, 70174, Stuttgart, Germany
| | - H U Kauczor
- Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, INF 110, 69120, Heidelberg, Germany
| | - T Hackert
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - C M Sommer
- Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, INF 110, 69120, Heidelberg, Germany. .,Clinic for Diagnostic and Interventional Radiology, Stuttgart Clinics, Katharinenhospital, Kriegsbergstrasse 60, 70174, Stuttgart, Germany.
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