Lymphatic Leaks of the Thigh and Inguinal Region: Combined Plastic Surgery Approaches for an Effective Treatment Algorithm.
Journal
Annals of plastic surgery
ISSN: 1536-3708
Titre abrégé: Ann Plast Surg
Pays: United States
ID NLM: 7805336
Informations de publication
Date de publication:
12 2020
12 2020
Historique:
pubmed:
3
3
2020
medline:
15
5
2021
entrez:
3
3
2020
Statut:
ppublish
Résumé
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. 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. 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. 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. 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.
Sections du résumé
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.
Identifiants
pubmed: 32118638
doi: 10.1097/SAP.0000000000002310
pii: 00000637-202012000-00020
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
661-667Références
Roberts JR, Walters GK, Zenilman ME, et al. Groin lymphorrhea complicating revascularization involving the femoral vessels. Am J Surg. 1993;165:341–344.
Chrobak L, Bartos V, Brzek V, et al. Coagulation properties of human thoracic duct lymph. Am J Med Sci. 1967;253:69–75.
Goldstein JA, Janu P, Fields B. Rectus femoris flap repair of recalcitrant inguinal lymphoceles after heart transplantation. J Heart Lung Transplant. 1994;13:549–554.
Van den Brande P, von Kemp K, Aerden D, et al. Treatment of lymphocutaneous fistulas after vascular procedures of the lower limb: accurate wound reclosure and 3 weeks of consistent and continuing drainage. Ann Vasc Surg. 2012;26:833–838.
Hamed O, Muck PE, Smith JM, et al. Use of vacuum-assisted closure (VAC) therapy in treating lymphatic complications after vascular procedures: new approach for lymphoceles. J Vasc Surg. 2008;48:1520–1523, e1521–e1524.
Twine CP, Lane IF, Williams IM. Management of lymphatic fistulas after arterial reconstruction in the groin. Ann Vasc Surg. 2013;27:1207–1215.
Stadelmann WK, Tobin GR. Successful treatment of 19 consecutive groin lymphoceles with the assistance of intraoperative lymphatic mapping. Plast Reconstr Surg. 2002;109:1274–1280.
Jones RM, Hart AM. Surgical treatment of a Morel-Lavallee lesion of the distal thigh with the use of lymphatic mapping and fibrin sealant. J Plast Reconstr Aesthet Surg. 2012;65:1589–1591.
Wang Q, Wang J, Li P. Lymphocele following liposuction in the thigh. Aesthetic Plast Surg. 2017;41:1408–1412.
Cnotliwy M, Gutowski P, Petriczko W, et al. Doxycycline treatment of groin lymphatic fistulae following arterial reconstruction procedures. Eur J Vasc Endovasc Surg. 2001;21:469–470.
Neu B, Gauss G, Haase W, et al. Radiotherapy of lymphatic fistula and lymphocele. Strahlenther Onkol. 2000;176:9–15.
Greer SE, Adelman M, Kasabian A, et al. The use of subatmospheric pressure dressing therapy to close lymphocutaneous fistulas of the groin. Br J Plast Surg. 2000;53:484–487.
Abai B, Zickler RW, Pappas PJ, et al. Lymphorrhea responds to negative pressure wound therapy. J Vasc Surg. 2007;45:610–613.
Lemaire V, Brilmaker J, Kerzmann A, et al. Treatment of a groin lymphatic fistula with negative pressure wound therapy. Eur J Vasc Endovasc Surg. 2008;36:449–451.
Dosluoglu HH, Loghmanee C, Lall P, et al. Management of early (<30 day) vascular groin infections using vacuum-assisted closure alone without muscle flap coverage in a consecutive patient series. J Vasc Surg. 2010;51:1160–1166.
Svensson S, Monsen C, Kolbel T, et al. Predictors for outcome after vacuum assisted closure therapy of peri-vascular surgical site infections in the groin. Eur J Vasc Endovasc Surg. 2008;36:84–89.
Giovannacci L, Renggli JC, Eugster T, et al. Reduction of groin lymphatic complications by application of fibrin glue: preliminary results of a randomized study. Ann Vasc Surg. 2001;15:182–185.
Schwartz MA, Schanzer H, Skladany M, et al. A comparison of conservative therapy and early selective ligation in the treatment of lymphatic complications following vascular procedures. Am J Surg. 1995;170:206–208.
Haaverstad R, Urnes O, Dahl T, et al. Lymphatic complications after lower limb vascular surgery. Tidsskr Nor Laegeforen. 1996;116:1886–1888.
Steele SR, Martin MJ, Mullenix PS, et al. Intraoperative use of isosulfan blue in the treatment of persistent lymphatic leaks. Am J Surg. 2003;186:9–12.
Nakamura Y, Fujisawa Y, Maruyama H, et al. Intraoperative mapping with isosulfan blue of lymphatic leakage during inguinal lymph node dissection (ILND) for skin cancer for the prevention of postoperative lymphocele. J Surg Oncol. 2011;104:657–660.
Shermak MA, Yee K, Wong L, et al. Surgical management of groin lymphatic complications after arterial bypass surgery. Plast Reconstr Surg. 2005;115:1954–1962.
Boccardo F, Dessalvi S, Campisi C, et al. Microsurgery for groin lymphocele and lymphedema after oncologic surgery. Microsurgery. 2014;34:10–13.
Blana A, Denzinger S, Lenhart M, et al. Treatment of a recurrent inguinal lymphocele in a penis cancer patient by lymphography and selective ligation of lymphatic vessels. Int J Urol. 2007;14:450–451.
Sorelius K, Schiraldi L, Giordano S, et al. Reconstructive surgery of inguinal defects: a systematic literature review of surgical etiology and reconstructive technique. In Vivo. 2019;33:1–9.
Toyserkani NM, Nielsen HT, Bakholdt V, et al. Ligation of lymph vessels for the treatment of recurrent inguinal lymphoceles following lymphadenectomy. World J Surg Oncol. 2016;14:9.
Kwaan JH, Bernstein JM, Connolly JE. Management of lymph fistula in the groin after arterial reconstruction. Arch Surg. 1979;114:1416–1418.
Scaglioni MF, Arvanitakis M, Chen YC, et al. Comprehensive review of vascularized lymph node transfers for lymphedema: outcomes and complications. Microsurgery. 2018;38:222–229.
Scaglioni MF, Suami H. Lymphatic anatomy of the inguinal region in aid of vascularized lymph node flap harvesting. J Plast Reconstr Aesthet Surg. 2015;68:419–427.
Guiotto M, Bramhall RJ, Campisi C, et al. A systematic review of outcomes after genital lymphedema surgery: microsurgical reconstruction versus excisional procedures. Ann Plast Surg. 2019;83:e85–e91.
Medgyesi S. A successful operation for lymphoedema using a myocutaneous flap as a “wick”. Br J Plast Surg. 1983;36:64–66.
Laustsen J, Bille S, Christensen J. Transposition of the sartorius muscle in the treatment of infected vascular grafts in the groin. Eur J Vasc Surg. 1988;2:111–113.