Technik und Morbidität der radikalen inguinal / iliakalen Lymphknoten­dissektion – eine prospektive Untersuchung an 67 Patienten mit lymphogen metastasiertem malignen Melanom

[Complications and their management following axillary, inguinal and iliac lymph node dissection]

Irrespective of numerous technical developments, lymphadenectomy remains a necessary component of surgical tumor therapy. Depending on the extent and anatomical localization, complications associated with the lymph vessels such as lymphoceles, lymphatic fistulas or secondary lymphedema can occur with varying frequency, despite a meticulous dissection technique. Chronic lymph fistulas or lymphoceles often require interventional or surgical procedures. Pedicled or free microsurgical flaps are often required in the case of coexisting wound healing disorders or skin soft tissue defects, especially in an irradiated area. For secondary lymphedema a number of conservative and surgical treatment methods have been established. Adequate guideline-based conservative treatment is the method of first choice. If this does not lead to the desired result, microsurgical reconstructive, deviating or resecting procedures are available.

Definition and severity grading of postoperative lymphatic leakage following inguinal lymph node dissection

Purpose

Lymphatic complications occur frequently after radical inguinal lymph node dissection (RILND). The incidence of lymphatic leakage varies considerably among different studies due to the lack of a consistent definition. The aim of the present study is to propose a standardized definition and grading of different types of lymphatic leakage after groin dissection.

Methods

A bicentric retrospective analysis of 82 patients who had undergone RILND was conducted. A classification of postoperative lymphatic leakage was developed on the basis of the daily drainage output, any necessary postoperative interventions and reoperations, and any delay in adjuvant treatment.

Results

In the majority of cases, RILND was performed in patients with inguinal metastases of malignant melanoma (n = 71). Reinterventions were necessary in 15% of the patients and reoperations in 32%. A new classification of postoperative lymphatic leakage was developed. According to this definition, grade A lymphatic leakage (continued secretion of lymphatic fluid from the surgical drains without further complications) occurred in 13% of the patients, grade B lymphatic leakage (persistent drainage for more than 10 postoperative days or the occurrence of a seroma after the initial removal of the drain that requires an intervention) in 28%, and grade C lymphatic leakage (causing a reoperation or a subsequent conflict with medical measures) in 33%. The drainage volume on the second postoperative day was a suitable predictor for a complicated lymphatic leakage (grades B and C) with a cutoff of 110 ml.

Conclusion

The proposed definition is clinically relevant, is easy to employ, and may serve as the definition of a standardized endpoint for the assessment of lymphatic morbidity after RILND in future studies.

Value and Diagnostic Accuracy of Ultrasound-Guided Full Core Needle Biopsy in the Diagnosis of Lymphadenopathy: A Retrospective Evaluation of 793 Cases

OBJECTIVES

Whole surgical lymph node excision (SNE) is considered the standard diagnostic method in the primary diagnosis of lymphadenopathy (LA) suspected of malignancy. Ultrasound-guided full core needle biopsy (UFCNB) offers an alternative method to SNE. This study examined the accuracy of UFCNB in the diagnosis of unexplained LA in 793 cases.

METHODS

From January 2006 to June 2015, a total of 793 cases of LA of unknown origin received a UFCNB. The lymph nodes were located peripherally (68%) or abdominally (32%). The final diagnoses from histopathologic examinations were non-Hodgkin lymphoma (n = 245), Hodgkin lymphoma (n = 53), solid nonlymphocytic lymph node metastases (n = 359), and benign LA (n = 136). The results of the biopsies were retrospectively evaluated with regard to sensitivity, specificity, and diagnostic accuracy.

RESULTS

In the total collective of 793 biopsies, the sensitivity of UFCNB was 94.4%; the specificity was 97.8%; and the diagnostic accuracy was 95.0%. In the subgroups, the following results were obtained: non-Hodgkin lymphoma (sensitivity, 97.2%), Hodgkin lymphoma (sensitivity, 88.7%), metastases (sensitivity, 93.3%), and benign LA (specificity, 97.8%). In 17 cases (2.2%), an additional rebiopsy of the lymph node was needed, and in 85 cases (10.7%), an additional SNE was performed.

CONCLUSIONS

Due to the diagnostic accuracy of 95.0% in the total collective, UFCNB seems to be an alternative diagnostic procedure to the standard procedure of SNE for LA of unknown origin. A prospective comparative study to definitively clarify the diagnostic value of UFCNB compared to SNE in the unexplained LA is warranted.

Identification of Risk Factors in Lymphatic Surgeries for Melanoma: A National Surgical Quality Improvement Program Review

INTRODUCTION

Sentinel lymph node biopsy (SLNB) and lymphadenectomy (LAD) are commonly performed in the staging and care of patients with malignant melanoma. These procedures are accompanied by complications that may result in hospital readmission, negatively affecting patient outcomes and potentially affecting surgical procedure reimbursement. The National Surgical Quality Improvement Program (NSQIP) database offers a large data set allowing physicians to evaluate 30-day readmission for surgical complications. We used this database to explore predictors of 30-day hospital readmission for SLNB and LAD in the axillary, cervical, and inguinal regions.

METHODS

Data from the years 2005 to 2014 of the American College of Surgeons NSQIP database were used. Cohorts were constructed according to International Classification of Diseases, Ninth Revision, classification and current procedural terminology codes. The outcome of 30-day return to hospital was defined as patients who were readmitted to the hospital or the operating room within 30 days. Multiple logistic regression results are presented for a prespecified set of predictors and predictors that were significant on univariate logistic regression analysis. Odds ratios and confidence intervals were calculated using maximum likelihood estimates, along with Wald test P values.

RESULTS

A total of 3006 patients were included. Of those, 151 (5.0%) returned to the hospital. Among 1235 LAD patients, 65 (5.3%) returned; among 1771 SLNB patients, 86 (4.9%) returned. Smoking was a predictor of hospital readmission for overall SLNB and for cervical SLNB on multivariate analysis. Age was a significant predictor for cervical and inguinal LAD. Hypertension was significant for cervical LAD. Diabetes, preoperative hematocrit, and male sex were predictors for inguinal SLNB. There were no significant predictors for axillary SLNB and axillary LAD, as well as overall LAD procedures.

CONCLUSIONS

This is the first and largest study using American College of Surgeons NSQIP to examine 30-day readmission after SLNB and LAD for melanoma in 3 commonly operated anatomical regions. We have found several significant risk factors associated with hospital readmission, which are now being used as a quality measure for hospital performance and reimbursement, that may help surgeons optimize patient selection for SLNB and LAD.

Quantity-guided drain management reduces seroma formation and wound infections after radical lymph node dissection: results of a comparative observational study of 374 melanoma patients

BACKGROUND

Lymphatic fistulas are common complications after lymph node dissections in melanoma patients. We investigated whether drain management could improve the patient's outcome.

METHODS

Patients who underwent axillary or inguinal lymph node dissection (RALND or RILND) for malignant melanoma were recorded in a prospective database. Two different methods of drain management were compared. Either the drain was removed no later than the eighth postoperative day (period I, 2003-2007) or it was left in place until fluid flow was below 50 ml in 24 h for two consecutive days (period II, 2008-2011). The main outcome criterion was the incidence of seroma punctures after drain removal.

RESULTS

374 patients were analysed. The incidence of seroma punctures significantly decreased in period II. The number of patients with elevated lymphatic secretions rose by 41.3% (RALND) and 38.1% (RILND). With the exception of lymphatic fistulas, we observed significantly more local complications with need for treatment in period I (n = 104, 52%) than in period II (n = 31, 18%). In period II, the hospital stays after both procedures were significantly reduced.

CONCLUSIONS

We conclude that quantity-guided drain management leads to a prolonged interval of drainage but is associated with a lower incidence of seroma formation and shorter hospital stay.

Influence of different positioning of a local pain catheter on postoperative pain after paramedian laparotomy-a blinded, randomized trial

BACKGROUND

Continuous application of local anaesthetics reduces postoperative pain after different approaches for laparotomy. In this randomized, blinded trial, we investigated the effect of continuous application of local anaesthetics after paramedian laparotomy either with subfascial or subcutaneous catheter in addition to a standardized systemic analgesia.

MATERIALS AND METHODS

Patients with stage III/IV melanoma and indication for radical iliac lymph node dissection (RILND) were randomized to a continuous application of a local anaesthetic through either a subfascial or subcutaneous catheter. Participants and those assessing the outcomes were blinded. The main outcome criterion was the pain level on the first postoperative morning while exercising measured with a visual analogue scale. Minor criteria were the pain measured by the area-under-curve until the third postoperative day, the patient's satisfaction with analgesic treatment, the analgesic requirement, the overall complications and the day of discharge.

RESULTS

Fifty-two patients were evaluated. Pain therapy was sufficient in both groups during the postoperative course while resting and during mobilization. There were no significant differences regarding the main and minor outcome criteria. Doses of additional analgesics did not differ between groups. No adverse events or side effects were observed.

CONCLUSION

For patients who undergo paramedian laparotomy, none of the investigated techniques is superior to the other at a median pain level under visual analogue scale (VAS) 30 mm on the first postoperative morning.

TRIAL REGISTRATION NUMBER

DRKS00003632 (German Register of Clinical Trials).

Reducing morbidity with surgical adhesives following inguinal lymph node dissections for the treatment of malignant skin tumors

Background: Inguinal lymph node dissection (ILND) is associated with a high rate of morbidity. To evaluate the clinical benefit of surgical adhesives to reduce complications in patients undergoing ILND, we compared the use of TissuGlu^® Surgical Adhesive and ARTISS^® fibrin sealant with a control population.

Material and methods: We conducted a retrospective analysis of patients undergoing ILND for metastatic malignant skin tumors at one hospital, Fachklinik Hornheide (Münster, Germany), from January 2011 through September 2013, assessing 137 patients with a total of 142 procedures.

Results: Complications occurred in 22/60 procedures in the TissuGlu group (TG), in 8/17 in the ARTISS group (AG), and in 29/65 in the control group (CG). Prolonged drainage and seroma were recorded in 16 (26.7%), four (23.5%), and 26 (40%) respectively (non-significant). TG showed less extended drainage vs. CG (p=0.082). Mean daily drain volumes were significantly lower in AG vs. CG (p=0.000). With regard to wound infection, there was a 15% reduction in TG and 74% increase in AG group. Revision surgery was reduced by 36% in TG and increased by 54% in AG. Mean daily drain volumes were significantly lower in AG vs. CG (p=0.000). Mean total post-operative drain volume was lower in TG and AG vs. CG (p<0.001 among groups, CG vs. TG p<0.001, CG vs. AG p<0.001). The mean body mass index (BMI) was significantly higher in patients with complications, 29.4±5.8 vs. 25.3±4.1 (p=0.000).

Conclusion: The use of TissuGlu in our ILND patients was associated with a reduction in post-operative wound related complications and the need for revision surgeries compared to the control group. Daily drainage was significantly lower within the first 7 post-operative days with the use of ARTISS, but the benefit was lost due to the higher occurrence of wound infection and revision surgery. BMI above 29 is a risk factor for complications following ILND.

(Level of evidence: level IV, retrospective case study)

Femoral hernia, a rare complication following deep inguinal lymph node dissection

A 72-year-old woman underwent complete deep inguinal lymph node dissection on her right side subsequent to metastasis from malignant melanoma. On the second postoperative day, the patient reported of nausea and vomiting. She presented with a mass in the resected area that gradually increased in size to approximately 15×20 cm. The wound was opened a few hours after onset of symptoms and a large femoral hernia with 40 cm of small intestine was immediately revealed protruding in the groin. Prophylactic suturing of the inguinal ligament and Coopers ligament can reduce the risk of postoperative femoral hernia. Further, the authors argue that drainage for seroma and haematoma should be performed with utmost care, considering other possible causes and, if necessary, guided by ultrasonography.

Cloquet's node trumps imaging modalities in the prediction of pelvic nodal involvement in patients with lower limb melanomas in Asian patients with palpable groin nodes

Patients with clinically palpable lymph node metastases to the groin are treated with groin dissection to control local disease and stage the malignancy. However, the extent of nodal dissection required to optimize survival rate is controversial.

AIM

To evaluate the approach to the extent of nodal dissection in advanced lower limb melanomas with clinically palpable inguinal nodes; to review survival outcomes based on the extent of nodal dissection and nodal disease.

MATERIALS AND METHODS

A prospectively maintained database of 12 patients with lower limb melanoma was analyzed. Cloquet's node was assessed based on the frozen section result which guided the decision to proceed to iliac-obturator dissection. The correlation of the results of the Cloquet's nodes and radiological imaging to the final histological outcome of groin nodal dissection were compared.

RESULTS

The positive predictive value (PPV) of radiological imaging in identifying pelvic nodal disease was 60%. PPV of a positive or indeterminate frozen section result of Cloquet's node was 71.4%. Notably, all patients with a positive frozen section result for the Cloquet's node had positive pelvic nodal disease. Median DFS for all patients is 26 months (range 3-68 months) and the median OS for all patients is 28.5 months (range 5-68 months). Median DFS for node negative patients was 28 months (range 24-68 months). Median DFS for node positive patients was 20 months (range 3-36 months).

CONCLUSION

Cloquet's node was shown to be superior to radiological imaging and should be preferentially used to decide on the extent of nodal dissection.

[Modified incomplete sartorius muscle flap for femoral vessel protection]

In exceptional cases bleeding of the femoral arteries after surgical interventions in the inguinal area can occur and in some cases can result in critical consequences with potential loss of limbs or fatal outcome. To prevent complications, especially after radical oncological surgery, a muscle flap is inserted to protect the vessel. In most cases the sartorius muscle is used because of its proximity to the operation area. This muscle also has the ideal size and a reliable and predictable position of nerves and vessels. The method of an incomplete sartorius muscle flap has considerable advantages in comparison with the complete method. The case presented is an example of modification of an incomplete sartorius muscle flap, which has been successfully applied in our clinic for extended inguinal dissection.

Continuous local analgesic therapy reduces pain after radical inguinal/iliacal lymph node dissection

BACKGROUND

To optimize postoperative pain therapy after a radical inguinal/iliacal lymph node dissection (RILND), we investigated the influence of a continuous application of a local anaesthetic via a subfascial wound catheter in the abdominal wall in addition to a standardized systemic analgesia.

MATERIALS AND METHODS

Between July 2007 and December 2009, 50 patients with stage III/IV of melanoma disease received, in an observational study, a systemic analgesic therapy. Of these patients, 30 were additionally treated with a subfascial catheter. Main outcome criterion was the pain under mobilisation at the first postoperative morning registered via a visual analogue score. Minor criteria were the analgesic requirement, the specific (surgical) complications and the day of discharge.

RESULTS

Patients treated with the subfascial catheter had significant less pain at the first postoperative morning in rest (p = 0.02) and after mobilisation (p = 0.03) without increased morbidity (p = 0.45). Less patients of the treatment group needed a supplementary analgesic medication (p = 0.01) and were able to leave hospital earlier than patients of the control group (p = 0.01).

CONCLUSIONS

A subfascially placed pain catheter enhances postoperative pain therapy after RILND.

A tie-over dressing for graft application in distal penectomy and glans resurfacing: the TODGA technique

OBJECTIVES

• To describe a novel method of split-skin graft (SSG) fixation for neo-glans formation after distal penectomy for penile cancer and glans resurfacing for carcinoma in situ or lichen sclerosus (LS); the TODGA technique. • Rather than 'quilting' the graft onto the neo-glans, which requires up to 5 days bed rest, the tie-over method fixes the graft adequately enough to allow immediate patient mobilization.

PATIENTS AND METHODS

• In all, 41 consecutive operations, with a follow-up of ≥ 12 months, were performed on 40 patients (mean age 62 years, range 32-83) from December 2000 to October 2008, where a SSG was applied to the raw glans or penile stump. • The protocol varied for the first 12 operations on 11 patients. The tie-over dressing was left in place for 6 (one patient) or 7 days (11) and various materials were used; paraffin gauze (one), expanded foam (five) and proflavine-soaked gauze (six). The first two patients had their dressing removed under general anaesthetic but all subsequent patients had their dressing removed on the ward. • The subsequent 29 operations used the same protocol where a proflavine-soaked gauze dressing was left undisturbed for 10 days.

RESULTS

• In the original 11 patients, two required re-grafting. After this initial development period, we amended the technique to use stronger sutures and left the dressing undisturbed for 10 days. • In addition, we standardized the use of proflavin-soaked gauze, as we found it easy to apply and remove. Since we adopted this protocol, we have performed 29 operations over a 3-year period. • The cosmetic results were excellent with only one patient requiring re-grafting. The mean and median postoperative length of stay was 2 days. • One patient with a urethral squamous cell carcinoma associated with urethral and glans LS required a urethral dilatation to allow a check cystoscopy, and a further asymptomatic patient had a meatal dilatation in the clinic but meatal stenosis was otherwise not seen, with no patients requiring regular meatal dilatation.

CONCLUSION

• The TODGA technique of SSG application and fixation allows immediate mobilization and reduces hospital stay whilst providing excellent cosmetic results with a high percentage of graft uptake.