[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.

Radiotherapy of Lymphatic Fistulas after Vascular Surgery in the Groin

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.

Unusual Left Periclavicular Cutaneous Lymphatic Fistula After Port Explantation Without Lymph Vessel Injury: Imaging and Interventional Treatment

Complex oncological treatment can be associated with lymphatic vascular injury that is burdened by considerable morbidity. Lymphatic imaging and interventional techniques offer new minimally invasive treatment options. We report the case of a 59-year-old woman with an unusual lympho-veno-cutaneous fistula, diagnosed by magnetic resonance lymphangiography and treated by minimally invasive embolization therapy and venous recanalization.

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.

[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.

Treatment of postoperative high-volume lymphatic complications using isosulfan blue

BACKGROUND

Lymphocele (LC) and lymphocutaneous fistula (LF) are infrequent but serious complications that occur when lymphatics are disrupted during a vascular procedure. Conservative management with bed rest, extremity elevation, aspiration, and pressure dressing is often ineffective. This study evaluated the effectiveness of isosulfan blue (ISB) to identify disrupted lymphatics for ligation.

METHODS

Between 1998 and 2016, there were 33 lymphatic complications treated with ISB-directed ligation in 32 patients. The patients' records were retrospectively reviewed, recording demographics, comorbid conditions, index vascular operation causing the lymphatic complication, details of the procedure done to treat the lymphatic complication, and outcomes. In each patient, between 1 and 3 mL of ISB was injected in the subcutaneous tissue of the interdigital web space. The wound associated with the lymphatic complication was opened. The appearance of dye within the wound identified disrupted lymphatic ducts for suture ligation.

RESULTS

The lymphatic complications were either LC (11 [33%]) or LF (22 [66%]) and were associated with femoral vein harvest (9), great saphenous vein harvest (8), exposure of femoral arteries (13), creation of an upper extremity fistula (1), repeated femoral access for coronary angiography, or excision of an LC (1). Most patients were male (66%), and the mean age was 56.8 ± 13.1 years. In comparing patients with LF and LC, the diagnosis of LF was made earlier (13.8 ± 7.0 days vs 23.4 ± 14.1 days; P = .02), and treatment occurred sooner for LF than for LC (22.1 ± 8.1 days vs 48.8 ± 51.2 days; P = .02). In all patients, ISB identified one or more disrupted lymphatics. The appearance of the ISB dye within the wound after injection was rapid, often within 5 to 10 minutes. After ligation of the lymphatics, most wounds were closed primarily (26 [79%]), but a muscle flap (5 [15%]), negative pressure dressing (1 [3%]), and dressing changes (1 [3%]) were also used. Wound healing was achieved in all patients on average 32.5 ± 21.5 days after lymphatic ligation.

CONCLUSIONS

The current series is one of the largest reported experiences using ISB to identify injured lymphatics responsible for LC or LF. Lymphatic complications after a vascular procedure usually occur within 3 weeks of the index vascular procedure, with LF being identified and treated earlier than LC. ISB injection rapidly identifies disrupted extremity lymphatics. Ligation of these lymphatics results in reliable resolution of the lymphatic complication.

[Radiotherapeutic management of lymphatic fistulas : An effective but disregarded therapy option]

BACKGROUND

Lymphatic fistulas and lymphoceles are known complications after vascular surgery of the groin and after extended surgical interventions in the pelvic region. Unfortunately, conservative standard therapies are not always successful.

OBJECTIVES

Evaluation of the therapeutic efficacy and related side effects of percutaneous low-dose irradiation in patients with lymphorrhea and definition of its importance.

MATERIAL AND METHODS

Current presentation of previously published case series, reviews and guidelines.

RESULTS

The use of low-dose irradiation therapy with single doses of 0.3-0.5 Gy leads to a cessation of the lymphatic flow in a high percentage of patients when standard therapies do not show a sufficient effect. With cessation of lymphorrhea irradiation should be terminated. Acute side effects have not been reported and the risk of tumor induction is almost negligible.

CONCLUSION

Low-dose irradiation is an effective and very well-tolerated therapeutic alternative in the treatment of lymphatic fistulas and lymphorrhea when conservative therapies are unsuccessful.

Lymphangiography to treat postoperative lymphatic leakage: a technical review

In addition to imaging the lymphatics and detecting various types of lymphatic leakage, lymphangiography is a therapeutic option for patients with chylothorax, chylous ascites, and lymphatic fistula. Percutaneous thoracic duct embolization, transabdominal catheterization of the cisterna chyli or thoracic duct, and subsequent embolization of the thoracic duct is an alternative to surgical ligation of the thoracic duct. In this pictorial review, we present the detailed technique, clinical applications, and complications of lymphangiography and thoracic duct embolization.