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Vascular and Interventional Radiology |
1 From the Departments of Diagnostic Radiology (J.K.K., Y.Y.J., Y.H.K., Y.C.K., H.K.K.) and Obstetrics and Gynecology (H.S.C.), Chonnam University Medical School, 8 Hakdong, Dongku, Kwangju, 501-757 South Korea. Received May 18, 1998; revision requested July 14; revision received September 9; accepted February 12, 1999. Address reprint requests to J.K.K. (e-mail: kjkrad@chonnam.chonnam.ac.kr).
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Abstract |
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MATERIALS AND METHODS: Percutaneous catheter drainage of 23 symptomatic lymphoceles was performed with ultrasonographic (US) guidance in 20 patients who had undergone radical pelvic lymphadenectomy because of uterine malignancy. All lymphoceles were diagnosed on the basis of biochemical and cytologic findings in aspirated fluid. The drainage catheter was removed when the amount of daily drainage was less than 10 mL per day and when the lymphocele was seen at imaging to have resolved. Follow-up US was performed at 1, 3, and 6 months after catheter removal. The results were classified as success, partial success, or failure.
RESULTS: Lymphoceles ranged in size from 5 x 4 x 3 to 25 x 10 x 10 cm. Mean total drainage volume was 2,012 mL (range, 300–17,240 mL). Fluid from 10 lymphoceles (43%) was positive at Gram staining and bacteriologic culture; fluid from 13 (57%) was sterile. Duration of catheter drainage was 3–49 days (mean, 22 days). Twenty (87%) lymphoceles resolved completely; three (13%) recurred. Two recurrent lymphoceles were again treated with percutaneous catheter drainage; the third resolved spontaneously 5 months after catheter removal. Successful treatment was ultimately achieved in all patients. Postprocedural complications occurred in four patients. One had a secondary infection of lymphocele; one, catheter dislodgment; and two, skin infection at the site of catheter insertion.
CONCLUSION: Percutaneous catheter drainage is safe and effective for treatment of symptomatic postoperative lymphoceles.
Index terms: Cyst, percutaneous drainage, 992.1263 • Lymphatic system, interventional procedure, 992.123, 992.1263 • Lymphocele, 992.842
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Introduction |
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The purpose of this study was to analyze the results and evaluate the effectiveness of simple percutaneous catheter drainage of pelvic or retroperitoneal lymphoceles in patients who had undergone radical pelvic lymph node dissection because of uterine malignancy.
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MATERIALS AND METHODS |
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Fifteen lymphoceles were detected at ultrasonography (US); three, at computed tomography (CT); and five, at both US and CT. Lymphoceles were located in the pelvic cavity (n = 8), retroperitoneal cavity (n = 6), or both cavities (n = 9). The time between surgery and catheter drainage was 7–219 days (mean, 68 days). No patient had previously undergone surgery for treatment of a lymphocele. Indications for drainage were abdominal pain in all patients, fever and chills in 13 patients, edema of lower extremities and external genitalia in 10 patients, palpable pelvic mass in eight patients, and ipsilateral hydronephrosis in two patients.
Before the procedure, a complete blood count and biochemical analysis was performed to evaluate for the likelihood of bleeding. Prophylactic antibiotics (piperacillin sodium and amikacin sulfate) were administered 24 hours before the procedure. The patients received nothing by mouth for 6 hours before the procedure.
In all patients, US was performed to determine the relationship between the lymphocele(s) and adjacent abdominal organs and to choose the safest and shortest approach. Routes of approach were transperitoneal in 16 cases amd retroperitoneal in seven.
By using sterile procedures and US guidance, the lesion was punctured with a 21-gauge Chiba needle (Jung Sung, Seoul, South Korea). Approximately 15 mL of fluid was aspirated for the purposes of biochemical, cytologic, and bacteriologic examinations. A lymphocele was diagnosed when the creatinine, urea nitrogen, protein, and electrolyte components of aspirated fluid were similar to those of serum at the biochemical examination and when the aspirated fluid had few leukocytes, predominant lymphocytes, and no cancer cells at the cytologic examination (4–8).
For initial lymphography, the lymphocele was opacified with diluted contrast medium (Urografin 60%; Schering, Berlin, Germany) injected through the Chiba needle. Insertion of a 0.018-inch guide wire was followed by removal of the puncture needle. A 6.3-F sheath (MEDIKIT; Jung Sung) was then inserted over the wire. As much fluid as possible was aspirated through this sheath to prevent contamination from adjacent organs.
The second lymphographic procedure was performed through the 6.3-F sheath to evaluate the size of the lesion and internal septation. A 0.038-inch guide wire (Boston Scientific/Medi-tech, Natick, Mass) was inserted. If internal septation was seen, the septum was broken by using the guide wire with fluoroscopic guidance. Next, an 8.0–10.2-F pigtail drainage catheter (Boston Scientific/Microvasive, Natick, Mass) was inserted into the cavity after removal of sheath. The tip of the catheter was left at the most dependent position of the cavity to facilitate spontaneous drainage by means of gravity. The drainage catheter was irrigated three to five times per day with 5–10 mL of physiologic saline solution, and the amount of drainage was recorded. Follow up US (n = 15) or lymphography (n = 8) was performed 1 week later to help evaluate the size of the lymphocele.
The catheter was removed when the following criteria were met: Drainage had stopped or was less than 10 mL per day for more than 3 days and when the cavity was seen to be collapsed at US or lymphography. The patient was discharged when lymphocele-related symptoms were relieved. All patients were followed up with US in the outpatient department at 1, 3, and 6 months after catheter removal.
Results were defined as follows: Complete success was achieved when abnormal fluid collections seen at US had collapsed, lymphocele-related symptoms were relieved, there was no recurrence at follow-up, and there was no need for surgical management. Partial success was achieved when a lymphocele recurred but resolved without surgical management. The result was classified as a failure when clinical symptoms were aggravated, and the lymphocele was managed with surgical intervention.
The correlations of duration of drainage with size of lymphocele and presence of secondary infection were analyzed by using the Spearman correlation method.
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RESULTS |
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Lymphocele size varied between 5 x 4 x 3 cm and 25 x 10 x 10 cm. The total volume of drained fluid was 300–17,240 mL (mean, 2,012 mL). Lymphocele-related symptoms were relieved within 3 days after the procedure in all patients. The duration of catheter drainage was 3–49 days (mean, 22 days). There were no significant differences between lesion size and drainage duration (P = .072) and between mean drainage duration in noninfected lymphoceles (18.8 days) and that in infected lymphoceles (24.9 days) (P = .9688).
Twenty lymphoceles (87%) were completely obliterated after initial catheter drainage. Recurrence was noted in three lymphoceles (13%). In two of these, obliteration occurred after a second catheter drainage procedure; the third lymphocele, which was small and produced no symptoms, completely resolved after 5 months without any further treatment (Fig 2). As a result, successful percutaneous catheter drainage was attained in all cases.
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DISCUSSION |
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In histologic terms, the wall of a lymphocele consists of dense fibrotic tissue with no lining of epithelial cells. The wall of a lymphocele does not infiltrate adjacent structures (3). A lymphocele must be differentiated from a postoperative urinoma, hematoma, seroma, or abscess, but this is difficult on the basis of radiologic results alone. At biochemical analysis, a lymphocele has the same levels of protein, urea nitrogen, creatinine, electrolytes, and, occasionally, lipids as serum has, so differentiation from urinoma, hematoma, seroma, or abscess is possible (4–9). In our study, the urea nitrogen, creatinine, and electrolytes levels in lymphoceles were similar to those in serum in all cases, and three retroperitoneal lymphoceles had levels of lipids and triglycerides that were higher than those of serum.
The natural course of a lymphocele usually is dependent on the size of the lesion and the presence of infection. When a lymphocele is small and sterile, it usually heals by means of spontaneous resorption. When it is large, however, the lymphocele may compress adjacent structures such as the iliac vessels, bladder, ureter, or rectosigmoid (3–8). This compression causes manifestations that include abdominal distention, abdominal and pelvic pain, hydronephrosis, bladder dysfunction, constipation, tenesmus, edema of the ipsilateral leg and of the genitalia, and thromboembolism of iliac vessels.
When complications such as abdominal pain, fever, chills, and sepsis develop (3–8), surgical treatment or catheter drainage is necessary. Indications for treatment usually are determined on the basis of the severity of clinical symptoms and the presence of functional compromise of adjacent vital structures (10–15). In our study, all 23 lymphoceles produced clinical symptoms. Ten lymphoceles (43%) produced symptoms associated with infection of the lymphocele.
There are several methods for treatment of a lymphocele, including surgical drainage, peritoneal marsupialization, simple aspiration, percutaneous catheter drainage, and percutaneous catheter drainage with sclerotherapy (4–12). When surgery was the only available therapeutic option, surgical drainage resulted in a success rate of 50%–70%, and peritoneal marsupialization resulted in a success rate of greater than 90% (16). However, these methods have some disadvantages, such as surgical morbidity and mortality, economic burden, and the need for long hospitalization (3,4).
Simple aspiration is safer and more effective than surgical therapy, but repeated procedures are necessary in 80%–90% of patients, and an infection rate of 25%–50% has been reported (5,7,9). Conte et al (9) reported a mean drainage duration of 14.5 days and a success rate of 100% with simple percutaneous catheter drainage. White et al (6) and vanSonnenberg et al (5) reported catheter drainage durations, either with or without sclerotherapy, of 4–120 days and 5–32 days, respectively, and success rates of 82% and 79%, respectively.
Sclerotherapy with the use of tetracycline, ampicillin, povidone-iodine, or alcohol usually results in a high success rate of 79%-93% (3,4,7,8). Akhan et al (7), Zuckerman and Yeager (8), and Sawhney et al (4) reported that percutaneous catheter drainage combined with alcohol sclerotherapy results in average drainage durations of 9, 19, and 36 days, respectively, and success rates of 88%, 94%, and 100%, respectively. In our study, the mean duration of lymphocele drainage was 22 days. Inflammatory changes in an infected lymphocele render the lymphocele adhesive, which results in a short drainage duration. We achieved successful treatment of postoperative lymphoceles by means of simple catheter drainage in all cases, with no important complications and no need for secondary surgical treatment.
Percutaneous catheter drainage has some advantages; namely, no need to perform sclerotherapy and an only infrequent need for a repeated procedure. These advantages result in a lower economic burden for the patient. Sclerotherapy with absolute alcohol causes an intense inflammatory reaction during the obliteration of injured lymphatic channels that maintain persistent fluid output. Absolute alcohol dehydrates cells and degrades proteins in the layers of tissue. The effects of alcohol are followed by inflammatory changes and scarring (4,8). Other sclerosing agents, including tetracycline and povidone-iodine, cause similar inflammatory effects (4).
In our study, there was no statistical correlation between the size of the lymphocele and the duration of drainage. Drainage duration was longer for infected lymphoceles (mean, 24.9 days) than for sterile lymphoceles (mean, 18.8 days), but this difference was not significant.
No serious catheter-related complications necessitating further therapy have been reported (8). Likewise, no major complications were encountered in this study; minor complications included skin infection, secondary infection of the lymphocele, and dislodgment of the catheter.
In conclusion, percutaneous catheter drainage without sclerotherapy is a simple and effective therapeutic method that results in a high success rate in the treatment of a symptomatic lymphocele after radical pelvic lymphadenectomy performed because of uterine malignancy.
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Footnotes |
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References |
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This article has been cited by other articles:
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  B J. d'Othee and D Ghiorse Non-infected, non-haematic fluid collections after endovenous laser ablation of the saphenous veins: a noteworthy complication Phlebology, January 1, 2008; 23(1): 47 - 49. [Abstract] [Full Text] [PDF]
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