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Jazmati D, Tamaskovics B, Hoff NP, Homey B, Bölke E, Boyomo B, Garabet W, Haussmann J, Budach W, Neuwahl J, Schelzig H, Corradini S, van Griensven M, Fischer J, Knoefel WT, Pegani J, Pedoto A, Antoch G, Kirchner J, Lüdde T, Freise NF, Feldt T, Jensen BEO, Keitel V, Matuschek C. Percutaneous fractionated radiotherapy of the groin to eliminate lymphatic fistulas after vascular surgery. Eur J Med Res 2023; 28:70. [PMID: 36755343 PMCID: PMC9909919 DOI: 10.1186/s40001-023-01033-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 01/26/2023] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND Vascular surgery of the inguinal area can be complicated by persistent lymphatic fistulas. Rapid and effective treatment is essential to prevent infection, sepsis, bleeding, and possible leg amputation. Current data on irradiation of lymphatic fistulas lack recommendation on the appropriate individual and total dose, the time of irradiation, and the target volume. Presumably, a dose of 0.3-0.5 to 1-12 Gy should be sufficient for the purpose. Currently, radiotherapy is a "can" recommendation, with a level 4 low evidence and a grade C recommendation, according to the DEGRO S2 guidelines. As part of a pilot study, we analyzed the impact and limitations of low-dose radiation therapy in the treatment of inguinal lymphatic fistulas. PATIENTS AND METHODS As a part of an internal quality control project, patients with lymphatic fistulas irradiated in the groin area after vascular surgery for arterial occlusive disease (AOD) III-IV, repair of pseudo aneurysm or lymph node dissection due to melanoma were selected, and an exploratory analysis on retrospectively collected data performed. RESULTS Twelve patients (10 males and 2 females) aged 62.83 ± 12.14 years underwent open vascular reconstruction for stage II (n = 2), III (n = 1), and IV (n = 7) arterial occlusive disease (AOD), lymph node dissection for melanoma (n = 1) or repair of a pseudoaneurysm (n = 1). Surgical vascular access was obtained through the groin and was associated with a persistent lymphatic fistula, secreting more than 50 ml/day. Patients were irradiated five times a week up to a maximum of 10 fractions for the duration of the radiation period. Fraction of 0.4 Gy was applied in the first 7 cases, while 5 patients were treated with a de-escalating dose of 0.3 Gy. There was a resolution of the lymphatic fistula in every patient without higher grade complications. CONCLUSION Low-dose irradiation of the groin is a treatment option for persistent lymphatic fistula after inguinal vascular surgery.
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Affiliation(s)
- Danny Jazmati
- grid.14778.3d0000 0000 8922 7789Department of Radiation Oncology, University Hospital Dusseldorf, Medical Faculty, Heinrich-Heine University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Bálint Tamaskovics
- grid.14778.3d0000 0000 8922 7789Department of Radiation Oncology, University Hospital Dusseldorf, Medical Faculty, Heinrich-Heine University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Norman-Philipp Hoff
- grid.14778.3d0000 0000 8922 7789Department of Dermatology, Medical Faculty, Heinrich Heine University Hospital Dusseldorf, Düsseldorf, Germany
| | - Bernhard Homey
- grid.14778.3d0000 0000 8922 7789Department of Dermatology, Medical Faculty, Heinrich Heine University Hospital Dusseldorf, Düsseldorf, Germany
| | - Edwin Bölke
- Department of Radiation Oncology, University Hospital Dusseldorf, Medical Faculty, Heinrich-Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - Belebenie Boyomo
- grid.14778.3d0000 0000 8922 7789Department of Radiation Oncology, University Hospital Dusseldorf, Medical Faculty, Heinrich-Heine University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Waseem Garabet
- grid.14778.3d0000 0000 8922 7789Department of Vascular Surgery, Medical Faculty, Heinrich Heine University Hospital Dusseldorf, Düsseldorf, Germany
| | - Jan Haussmann
- grid.14778.3d0000 0000 8922 7789Department of Radiation Oncology, University Hospital Dusseldorf, Medical Faculty, Heinrich-Heine University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Wilfried Budach
- grid.14778.3d0000 0000 8922 7789Department of Radiation Oncology, University Hospital Dusseldorf, Medical Faculty, Heinrich-Heine University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Judith Neuwahl
- grid.14778.3d0000 0000 8922 7789Department of Radiation Oncology, University Hospital Dusseldorf, Medical Faculty, Heinrich-Heine University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Hubert Schelzig
- grid.14778.3d0000 0000 8922 7789Department of Vascular Surgery, Medical Faculty, Heinrich Heine University Hospital Dusseldorf, Düsseldorf, Germany
| | - Stefanie Corradini
- grid.5252.00000 0004 1936 973XDepartment of Radiation Oncology, LMU University of Munich, Munich, Germany
| | - Martijn van Griensven
- grid.5012.60000 0001 0481 6099MERLN Institute for Technology-Inspired Regenerative Medicine, Department cBITE, Maastricht University, Maastricht, The Netherlands
| | - Johannes Fischer
- grid.411339.d0000 0000 8517 9062Institute for Transplant Diagnostics and Cell Therapeutics, University Hospital, Leipzig, Germany
| | - Wolfram Trudo Knoefel
- grid.14778.3d0000 0000 8922 7789Department of Surgery and Interdisciplinary Surgical Intensive Care Unit, University Hospital Dusseldorf, Medical Faculty, Heinrich-Heine-University, Dusseldorf, Germany
| | | | - Alessia Pedoto
- grid.51462.340000 0001 2171 9952Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY USA
| | - Gerald Antoch
- grid.14778.3d0000 0000 8922 7789Department of Diagnostic and Interventional Radiology, Medical Faculty University Hospital of Dusseldorf, Dusseldorf, Germany
| | - Julian Kirchner
- grid.14778.3d0000 0000 8922 7789Department of Diagnostic and Interventional Radiology, Medical Faculty University Hospital of Dusseldorf, Dusseldorf, Germany
| | - Tom Lüdde
- grid.14778.3d0000 0000 8922 7789Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Dusseldorf, Medical Faculty, Heinrich-Heine-University, Dusseldorf, Germany
| | - Noemi F. Freise
- grid.14778.3d0000 0000 8922 7789Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Dusseldorf, Medical Faculty, Heinrich-Heine-University, Dusseldorf, Germany
| | - Torsten Feldt
- grid.14778.3d0000 0000 8922 7789Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Dusseldorf, Medical Faculty, Heinrich-Heine-University, Dusseldorf, Germany
| | - Björn-Erik Ole Jensen
- grid.14778.3d0000 0000 8922 7789Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Dusseldorf, Medical Faculty, Heinrich-Heine-University, Dusseldorf, Germany
| | - Verena Keitel
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Medical Faculty, Otto-Von-Guericke-Universität Magdeburg, Magdeburg, Germany
| | - Christiane Matuschek
- grid.14778.3d0000 0000 8922 7789Department of Radiation Oncology, University Hospital Dusseldorf, Medical Faculty, Heinrich-Heine University, Moorenstr. 5, 40225 Düsseldorf, Germany
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Hautmann MG, Dietl B, Wagner L, Zeman F, Kölbl O, Pfister K, Schierling W. Radiotherapy of Lymphatic Fistulas after Vascular Surgery in the Groin. Int J Radiat Oncol Biol Phys 2021; 111:949-958. [PMID: 34324999 DOI: 10.1016/j.ijrobp.2021.07.1696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/16/2021] [Accepted: 07/20/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE Lymphatic fistulas are common complications after vascular surgery especially in the groin, which can lead to a prolongation of the inpatient stay, wound infections and follow-up operations. Radiotherapy is one of the non-surgical treatment options. However, there is limited evidence and discussion about the ideal dosage and timing. METHODS AND MATERIALS The analysis was performed on patients from a German university hospital and included 191 patients with 206 lymphatic fistulas from 2005 to 2016. Four different endpoints were analyzed. The patients were irradiated with a fraction dose of 3 Gy up to a cumulative dose of 9 Gy (94/206 cases) or 18 Gy (112/206 cases). The median age of the patients was 70.5 years with 74% male and 26% female patients. Vascular surgery included bypass grafts (52%), thrombendarterectomy/patch angioplasty (26%), and vascular access for aortic endografts (22%). RESULTS The response to radiotherapy for the four different endpoints was 88% (25% decrease in secretion volume), 80% (secretion below 50 ml/24 hours), 81% (removal of the drainage) and 75% (freedom from any intervention), respectively. The overall response for all four endpoints was 63% (129/206) after completion of radiotherapy, and 34% (70/206) after one course with a total dose up to 9 Gy. The median lymphatic secretion was 150 ml/24 hours before radiotherapy and 60 ml/24 hours one day after the end of therapy. The drainage could be removed a median of 3 days after radiotherapy completion. There was no significant difference between patients starting the radiation within 5-9 days or ≥10 days postoperatively (p = .971 OR = 0.99; 95%-CI: 0.56 to 1.74). No relevant factors influencing the response rate could be identified. Re-operation was required in 50/206 cases (25%), in 24/206 cases (12%) due to persistent lymphatic fistula and complications and in 26/206 cases (13%) due to wound and/or vascular complications. CONCLUSION Radiotherapy seems to be an effective, non-surgical treatment option for reducing lymphatic secretion after vascular surgery in the groin. Starting radiation early (≤9 days) or late (≥10 days) postoperatively does not affect the success rate.
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Affiliation(s)
- Matthias G Hautmann
- Department of Radiotherapy, University Hospital Regensburg, Regensburg, Germany.
| | - Barbara Dietl
- Department of Radiotherapy, University Hospital Regensburg, Regensburg, Germany
| | - Laura Wagner
- Department of Vascular Surgery, University Hospital Regensburg, Regensburg, Germany; Public Health Department, Cologne, Germany
| | - Florian Zeman
- Centre for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - Oliver Kölbl
- Department of Radiotherapy, University Hospital Regensburg, Regensburg, Germany
| | - Karin Pfister
- Department of Vascular Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Wilma Schierling
- Department of Vascular Surgery, University Hospital Regensburg, Regensburg, Germany
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Wellkamp L, Dellmann NC, Bushart S, Al-Shakhanbeh M, Kirchhoff P, Ring A. [Fluorescence lymphangiography in the diagnosis and navigated microsurgical treatment of iatrogenic lymph vessel lesion]. Hautarzt 2021; 72:1094-1097. [PMID: 33721049 DOI: 10.1007/s00105-021-04795-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2021] [Indexed: 11/27/2022]
Abstract
Injuries of lymph vessels can occur due to trauma or surgery and may result in significant difficulties for patients. Wound healing is often severely impaired and patients may need extensive surgical treatment. A case of iatrogenic lymph vessel injury after excision of a skin tumor in the axillary region is reported, as is the reconstructive procedure by lymphaticovenous anastomosis.
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Affiliation(s)
- Lukas Wellkamp
- Klinik für Plastische Chirurgie und Handchirurgie, Zentrum für Rekonstruktive Lymphchirurgie, St. Rochus-Hospital, Glückaufstr. 10, 44575, Castrop-Rauxel, Deutschland
| | - Niklas-Chris Dellmann
- Klinik für Plastische Chirurgie und Handchirurgie, Zentrum für Rekonstruktive Lymphchirurgie, St. Rochus-Hospital, Glückaufstr. 10, 44575, Castrop-Rauxel, Deutschland
| | - Sebastian Bushart
- Klinik für Plastische Chirurgie und Handchirurgie, Zentrum für Rekonstruktive Lymphchirurgie, St. Rochus-Hospital, Glückaufstr. 10, 44575, Castrop-Rauxel, Deutschland
| | - Mutaz Al-Shakhanbeh
- Klinik für Plastische Chirurgie und Handchirurgie, Zentrum für Rekonstruktive Lymphchirurgie, St. Rochus-Hospital, Glückaufstr. 10, 44575, Castrop-Rauxel, Deutschland
| | - Pascal Kirchhoff
- Klinik für Plastische Chirurgie und Handchirurgie, Zentrum für Rekonstruktive Lymphchirurgie, St. Rochus-Hospital, Glückaufstr. 10, 44575, Castrop-Rauxel, Deutschland
| | - Andrej Ring
- Klinik für Plastische Chirurgie und Handchirurgie, Zentrum für Rekonstruktive Lymphchirurgie, St. Rochus-Hospital, Glückaufstr. 10, 44575, Castrop-Rauxel, Deutschland.
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