Lymphatic Leakage Research Articles

Lymphatic leaks – success of intranodal lymphangiogram first strategy

BackgroundLymphatic leaks are associated with significant mortality and morbidity. Intranodal lymphangiography (ILAG) involves the direct injection of ethiodised lipid into the hilum of lymph nodes. It is diagnostic procedure that can have therapeutic effects secondary to a local sclerosant effect. The aim of the study is to describe the technical and clinical success of ILAG and adjunctive lymphatic interventions performed as first line interventional techniques for lymphatic leaks refractory to conservative and medical management in a multicentre cohort of patients with symptomatic large volume lymphatic leaks.MethodsMulticentre retrospective study of all lymphatic interventions performed between 2017–2023 in patients with large volume lymphatic leaks (> 500 ml a day). Intranodal lymphangiography was performed initially with technical success defined as opacification of the lymphatics at the aortic bifurcation and demonstration of lymphatic leak on the index ILAG procedure or immediate post procedural CT was recorded. Lymphatic embolisation was performed with a combination of direct puncture or transvenous cannulation with glue and or coil embolisation of the thoracic duct or leak point and in cases with refractory leak. Clinical success was defined as reduction in drain output to less than 20 mL per 24 h, or no further insensible lymph leak. Time to clinical success after ILAG and adjunctive embolisation was recorded.ResultsILAG alone lead to clinical success in 14 of 32 (44%) patients after a median of 14 days. Subsequent embolisation was performed in 12 refractory cases; this was successful in 8 (67%) at median of 8 days. Overall clinical success of all lymphatic interventions was 69% (22 of 32 patients) at a median of 11 days (IQR 5–34). No statistically significant correlation between the site of leakage, aetiology or embolisation technique correlated with clinical success. Decision to proceed to repeat ILAG or an adjunct procedure was made on a clinical basis, following multidisciplinary discussion.ConclusionsILAG can be employed a first line interventional therapeutic technique to treat clinically significant lymphatic leaks that are refractory to conservative and medical management. Adjunctive procedures, including embolisation, can be considered as part of clinical decision making after a period of 1–2 weeks’ watchful waiting in continuingly refractory cases.

Confirmation of the importance of lymphatic leakage in the formation of axillary fluid collections after lymph node dissection for breast cancer

Confirmation of the importance of lymphatic leakage in the formation of axillary fluid collections after lymph node dissection for breast cancer

Nodal Lymphangiography and Embolization for Postoperative Lymphatic Leakage

Nodal Lymphangiography and Embolization for Postoperative Lymphatic Leakage

Comparative effectiveness totally endoscopic thyroidectomy via completely submental tri-hole approach and transoral endoscopic thyroidectomy without insufflation

ObjectiveThis study aims to evaluate the therapeutic effectiveness of totally endoscopic thyroidectomy via the completely submental tri-hole approach and transoral endoscopic thyroidectomy without insufflation.MethodsA total of 60 patients with thyroid tumors who were admitted to Panyu College Affiliated Hospital from August 2022 to August 2023 were collected in this study. The patients were divided into two groups, the transoral endoscopic thyroidectomy group (20 cases) and the totally endoscopic thyroidectomy via the completely submental tri-hole approach group (40 cases). Then, we evaluated the difference of surgical data, operative details, postoperative complications, duration of postoperative swelling, cosmetic satisfaction, discomfort during eating, and pain scores between two groups.ResultsThere were no significant differences between two groups in terms of operation time, intraoperative blood loss, postoperative drainage, extubation time, length of hospital stay, autotransplantation of parathyroid glands, or postoperative swelling. And neither group experienced voice hoarseness, postoperative bleeding, or lymphatic leakage. The incidence of hypocalcemia did not differ significantly between two groups, although the transoral endoscopic thyroidectomy group had a significantly higher incidence of chin numbness (p<0.01). Futhermore, there was no obvious differences in neck pain scores or cosmetic satisfaction scores at 3 days, 7 days, 2 weeks, and 1 month postoperatively. However, the discomfort during eating score was markedly lower in the totally endoscopic thyroidectomy group compared to the transoral endoscopic thyroidectomy group (P < 0.05).ConclusionTotally endoscopic thyroidectomy via the completely submental tri-hole approach offers advantages in reducing postoperative discomfort during eating compared to transoral endoscopic thyroidectomy, indicating promising prospects for clinical application.

Efficacy and Safety of LigaSure in Breast Surgery With Axillary Lymph Node Dissection in Patients With Breast Cancer: A Systematic Review and Meta-Analysis.

Conventional axillary lymph node dissection (ALND) is associated with significant post-operative morbidity in patients undergoing breast surgery due to increased lymphatic leakage. LigaSure, an electrothermal bipolar vessel sealing system, provides better closure of the leakage. This study aims to compare the efficacy and safety of LigaSure against conventional techniques in patients with breast cancer underwent ALND and breast surgery. We conducted a comprehensive search across the databases to identify relevant studies. The search results were imported into Covidence for article eligibility screening, and all relevant outcomes data were synthesized using odd ratios (ORs) or standardized mean differences (SMDs) with 95% confidence intervals (CIs) in meta-analysis models using RevMan 5.4. Twelve studies with the total of 895 patients (LigaSure = 441; Conventional technique = 454) with breast cancer underwent breast surgery with ALND were included. LigaSure was associated with significantly lower post-operative drain volume (SMD: -0.39, 95% CI [-0.53, -0.24], P < 0.00001), shortened duration of drain (SMD: -0.51, 95% CI [-0.67, -0.34], P < 0.00001), and reduced hospital stay length (SMD: -0.57, 95% CI [-0.96, -0.18], P = 0.004) compared to conventional techniques. However, no difference observed in total operation time, intra-operative blood loss, seroma related outcomes and post-operative complications between the two groups. LigaSure significantly reduced the lymphorrhea, duration of drain and hospital stay, however, it did not prove be effective in seroma-related outcomes.

Contrast-enhanced CT Lymphangiography for Various Central Lymphatic Disorders.

Lymphatic leakage, manifesting as chylothorax or chylous ascites, arises from traumatic or nontraumatic causes and poses severe risks such as malnutrition and increased infection susceptibility. Accurate diagnosis and an effective treatment strategy necessitate comprehensive lymphatic imaging. Conventional lymphangiography and dynamic contrast-enhanced MR lymphangiography (DCMRL) have been widely used and studied as effective lymphatic imaging methods. Recently, CT lymphangiography (CTL) has been successfully implemented in animal studies and some patients, and the authors' institution now prioritizes CTL over DCMRL. Contrast-enhanced CTL offers a promising alternative, with advantages such as better accessibility and faster imaging. These advantages of CTL over traditional methods highlight its superior accessibility and fast acquisition time. Moreover, to reduce and optimize radiation dose, the stepwise propagation scanning method in CTL could be used, which is especially beneficial in pediatric patients. In this review, the authors suggest the protocol for CTL and interpretation methods for evaluation and therapeutic planning of central lymphatic disorders, focusing on the condition of lymphatic leakage. ©RSNA, 2024 The slide presentation from the RSNA Annual Meeting is available for this article.

Pelvic Lymph Node Dissection With Polymer Ligation Clips Significantly Reduces Hospital Stay Compared to Vessel Sealer: A Retrospective Study.

Introduction Lymphocele is a typical complication of pelvic lymph node dissection (PLND) in robot-assisted radical prostatectomy (RARP). This study aimed to compare postoperative lymphatic leakage between the polymer ligation clip and vessel sealer, and evaluated the costs associated with the former. Methods The study enrolled patients who underwent RARP with PLND at our institution between April 2018 and March 2023and were treated with a vessel sealer (LigaSure Blunt Tip 44 NCTM; Medtronic, Dublin, Ireland) until September 2021, and Hem-o-lok polymer ligation clipsTM(Teleflex, Wayne, PA, USA) thereafter. The drain was removed on the third postoperative day or later, when the daily drainage volume was less than 200 mL. Results A total of 81 patients underwent RARP with PLND, which resulted in a significant increase in the operative (p = 0.016) and lymph node dissection times (p = 0.008) in the clip group. The total drainage volume (p = 0.048) was smaller, and the drain removal time (p = 0.039) and postoperative hospital stay (p < 0.001) were shorter in the clip group. Moreover, the device costs for the clips were lower than those for the vessel sealer. Conclusion Polymer ligation clips are associated with improved postoperative lymphatic leakage, shorter length of hospitalization, and lower costs, compared with vessel sealers.

Ultrasound-Guided Intranodal Lipiodol Lymphangiography for the Assessment and Treatment of Chylous Leaks: A Retrospective Case Series from a Single Center in Switzerland and a Systematic Review of the Literature.

Background: Lymphatic leaks are well-known complications of major thoracic or abdominal surgeries, which significantly heighten morbidity and mortality rates. While the existing literature provides insights into managing these post-operative leaks, with a step-up approach from conservative measures (CMs) to surgical intervention, there are no standardized treatment guidelines. The purpose of this paper is to offer a management algorithm of post-operative lymphatic leaks based on a systematic literature review (SLR) of the therapeutic effect of Lipiodol lymphangiography (LL), completed by a case series of five patients who underwent LL in our department. Methods: In this IRB-approved study, we conducted an SLR following the PRISMA guidelines, using a PICOS. A quality assessment was performed for each study. The case series consisted of consecutive patients who underwent LL for diagnostic and therapeutic purposes at our institution between September 2018 and December 2020. Results: A total of 39 observational studies were included in the SLR comprising 11 retrospective case reviews (Group 1), and 3 case series as well as 25 case reports (Group 2). In total, these studies report cases of 557 patients (51.52% presenting oncological diagnoses; 43.98% having benefited from lymphadenectomy). Lymphatic or chylous fistulas were the most encountered complication, followed by chylothorax. The median volume of Lipiodol injected during lymphography was 11.7 mL (range: 9.8-75 mL). Overall, LL was technically successful in 77.7% (366/471) of patients. The clinical success of all technically successful LLs was 80.6% (295/366). Time-to-leak resolution after lymphography varied between 1 and 31 days. The factors associated with treatment failure were a high leak output (>500 mL/day) and Lipiodol extravasation on post-LL imaging. Our case series consisted of five patients (mean age: 62 ± 9.24 years; 20% female; 100% oncological diagnoses; 60% having beneficiated from lymphadenectomy). Technical and clinical successes were 80% (4/5) and 75% (3/4), respectively. Time-to-leak resolution varied between 1 and 4 days. The volume and technique of LL was not different from that identified in the SLR. Conclusions: LL is a safe procedure with high technical and clinical success rates that could be proposed as both a diagnostic and therapeutic solution for patients with post-operative central lymphatic lesions.

The Role of Lymph-Adipose Crosstalk in Alcohol-Induced Perilymphatic Adipose Tissue Dysfunction.

Chronic alcohol use leads to metabolic dysfunction in adipose tissue. The underlying mechanisms and the contribution of alcohol-induced adipose tissue dysfunction to systemic metabolic dysregulation are not well understood. In our previous studies, we found that chronic alcohol feeding induces mesenteric lymphatic leakage, perilymphatic adipose tissue (PLAT) inflammation, and local insulin resistance in rats. The goal of this study was to further explore the link between alcohol-induced lymphatic leakage and PLAT immunometabolic dysregulation, locally and systemically, using in vivo and ex vivo approaches. Male rats received a Lieber-DeCarli liquid diet, of which 36% of the calories were from alcohol, for 10 weeks. Time-matched control animals were pair-fed. Adipokine levels were measured in PLAT, subcutaneous fat, plasma, and mesenteric lymph samples. Glucose tolerance was assessed after 10 weeks. Further, we used a novel ex vivo lymph-stimulated naïve PLAT explant approach to modeling lymph leakage to assess changes in adipokine secretion and expression of proinflammatory markers after stimulation with lymph from alcohol- or pair-fed animals. Our data show that chronic alcohol-fed rats presented PLAT-specific decreases in adiponectin and leptin levels, alterations in the expression of genes involved in lipid metabolic pathways, and associated impaired whole-body glucose homeostasis. Further, we found that direct naïve PLAT stimulation with lymph contents from alcohol-fed animals increased IL-6 expression in demonstrating the ability of lymph contents to differentially impact naïve adipose tissue. Overall, chronic alcohol feeding leads to depot-specific alterations in metabolic profile, impaired systemic glucose tolerance, and lymph-induced adipose tissue inflammation. The specific lymph components leading to PLAT immunometabolic dysregulation remain to be determined.

Clinical application of inferior pancreaticoduodenal artery management in laparoscopic pancreaticoduodenectomy

Objective: To investigate the clinical effect of proper management of inferior pancreaticoduodenal artery (IPDA) in laparoscopic pancreaticoduodenectomy (LPD). Methods: This is a retrospective case series study. The clinical and pathological data of 70 patients who received LPD due to pancreatic head tumors, periampullary tumors, or distal common bile duct tumors in the Pancreatic Center of the Second Clinical College of Guangzhou University of Chinese Medicine from January to December 2022 were retrospectively collected. There were 47 males(67.1%) and 23 females(32.9%),aged (59.9±12.8)years(range:13 to 87 years).The procedure of IPDA exposure was as follows:a middle approach was utilized to expose the right half of superior mesenteric artery(SMA) and its right branches between the SMA and superior mesenteric vein(SMV) in superior colonic region. In the subcolonic region,SMA trunk exposure via dissection along the jejunal artery from feet to head and identification the association between IPDA and jejunal artery were prior to IPDA root ligation and dissection. The safety and efficacy of intraoperative IPDA handling were assessed based on surgical videos. Follow-up was carried out in outpatient clinic or by telephone, and outpatient follow-up was conducted once every 1 to 3 months after surgery. Results: The percentage of total LPD was 98.6%(69/70),with all patients achieving R0 resection. Nine cases(12.9%) were involved in combined vascular resection and reconstruction,with 1 case (1.4%) requiring additional upper abdominal incision for vascular and gastrointestinal reconstruction,while the remaining eight cases (11.4%) were completed laparoscopically. The operative time was (432.7±115.4)minutes(range:282 to 727 minutes), and the blood loss was (140.0±125.7)ml(range:20 to 800 ml). Only two patients(2.9%) received fresh frozen plasma transfusion,with an average volume of 650 ml. Reliable ligation and safe handling of the IPDA were achieved in 91.4%(64/70) of cases, with 8.6%(6/70) suffering from IPDA injury-related bleeding. No one was converted to opened surgery. Pathologically,the mean tumor size was (3.3±1.6)cm (range:1 to 7 cm),and the mean number of harvested lymph nodes was 17.0±7.3(range:0 to 46). Lymph node metastasis was observed in 13 cases (18.6%). Five cases (13.2%) developed grade B pancreatic fistula,while no grade C pancreatic fistula occurred. Other complications included bile leakage in one case(1.4%),delayed gastric emptying in two cases(2.9%), lymphatic leakage in 2 cases(2.9%),intra-abdominal infection in 9 cases(12.9%),and fat liquefaction of surgical incision in 1 case(1.4%). Two cases(2.9%) experienced postoperative intra-abdominal bleeding,one due to mesangial bleeding of lesser curvature of the stomach and the other due to oozing from the hepatic arterial sheath. These bleeding events were not concerned with IPDA. The average length of postoperative hospital stay was (15.2±4.6)days(range:9 to 28 days). Conclusion: Proper intraoperative management of IPDA in LPD might reduce IPDA-related bleeding during and after surgery and improve the safety of LPD.

Lymphatic Fistula Treatment: Indocyanine Green Lymphography-guided Microsurgery

Background: Lymphatic fistulas are a common complication from surgery or interventional procedures resulting in persistent lymphatic leakage and delayed wound healing. The management of lymphatic fistula remains a subject of debate, ranging from conservative treatment to surgical lymphatic ligation. The implementation of a novel microsurgical approach involving lymphatic fistula ligation and/or lymphovenous anastomosis (LVA) using indocyanine green (ICG) lymphography is expected to decrease occurrence and complications. In this study, we share our experience in treating lymphatic fistula–guided microsurgical treatment. Methods: A total of 13 patients from our hospital with persistent lymphatic fistula were enrolled in this retrospective study. Lymphatic fistulas and their leakages were identified and ligated by using ICG lymphography and a surgical microscope. In two cases, additional LVA surgery was performed. Results: We were able to precisely identify lymphatic fistulas and treat them in all 13 patients. Lymph ligation was performed in all 13 cases, with additional distal LVA in two cases. In all patients, wound healing occurred following lymphatic ligation, except in one patient due to persistent infection. Patients with a lymphatic fistula were referred to our unit within 3 weeks to 1 year after onset, with an average consultation occurring after 5 months of persistent lymphatic fistula. Conclusions: Targeted lymphatic vessel ligation with or without LVA with ICG-guided surgical microscope represents a promising highly efficacious therapy for persistent lymphatic fistula. This technique may accelerate wound healing and reduce hospitalization duration, thus advocating for its preferential use in managing lymphatic fistulas.

Lymphatic embolization for early post-operative lymphatic leakage after radical cystectomy for bladder cancer.

Although radical cystectomy (RC) with pelvic lymph node dissection (PLND) is the standard treatment of muscle invasive bladder cancer, it may cause lymphatic leakage. Recent studies describe lymphatic embolization (LE) as an option to manage post-operative lymphatic leakage. Hence, this study evaluated the outcome of LE in patients receiving RC and analyzed factors associated with outcomes. This was a retrospective analysis of patients who underwent LE after RC for bladder cancer between August 2017 and June 2023. The data was assessed for analysis at January 2024. The patients were divided into a clinical success group and a clinical failure group. Clinical failure was defined as the following: 1) those who required drainage catheter placement >7 days after LE, 2) those who needed re-intervention before catheter removal, and 3) those who experienced adverse events associated with LE. Logistic regression analysis was performed to identify the factors associated with outcomes of LE. We analyzed 45 patients who underwent LE after RC. Twenty-eight (62.2%) patients were identified as clinically successful. Four patients required re-embolization, but none required more than two sessions of intervention. Three patients experienced lymphatic complications after LE. In multivariable analysis, maximal daily drainage volume of >1,000 mL/day (odds ratio [OR] = 4.729, 95% confidence interval [CI]: 1.018-21.974, p = 0.047) and diabetes mellitus (DM) (OR = 4.571, 95% CI: 1.128-18.510, p = 0.033) were factors associated with LE outcome. Our results suggest LE as a potentially effective procedure for controlling post-operative lymphatic leaks after RC, with few minor side effects. Patients exceeding a daily drainage of 1,000mL/day or with a medical history of DM have a higher risk for re-intervention and clinical failure after LE.

Lymphangiography Using Water-Soluble Contrast Media and Cone-Beam CT-Guided Sclerotherapy to Treat Infrainguinal Lymphatic Leak.

Lymphangiography Using Water-Soluble Contrast Media and Cone-Beam CT-Guided Sclerotherapy to Treat Infrainguinal Lymphatic Leak.

Characterizing Normal Upper Extremity Lymphatic Flow with 99mTc In-House Dextran: A Retrospective Study.

Lymphoscintigraphy evaluates the lymphatic system using radiocolloid compounds like 99mTc-sulfur colloid and 99mTc-nanocolloid, which vary in particle size and distribution timing. A local in-house Dextran kit (15-40 nm) was developed in 2005 and began clinical use in 2008 to localize sentinel lymph nodes; diagnose lymphedema; and detect lymphatic leakage. The normal drainage pattern remains unexplored. We retrospectively analyzed 84 upper extremity lymphoscintigraphies from 2008 to 2021. 99mTc in-house Dextran was intradermally injected into both hands, followed by whole-body imaging at specified intervals (≤15 min; 16-30 min; 31-45 min; 46-60 min), with some receiving delayed imaging. Visual and quantitative analyses recorded axillary and forearm lymph nodes and liver, kidney, and urinary bladder activity. Results showed 92% (77/84) upper extremity lymphatic tract visualization within 45 min. Axillary node detection rates increased from 46% (≤15 min) to 86% (46-60 min). Delayed imaging further revealed nodes. Epitrochlear or brachial node visualization was rare (4%, 3/84). Hepatic, renal, and urinary bladder activity was noted in 54%, 71%, and 93% at 1 h, respectively. The axillary node uptake ratio was minimal (<2.5% of injection site activity; median 0.33%). This study characterizes normal upper extremity lymphatic drainage using 99mTc in-house Dextran, offering insights into its clinical application.

ICG mapping of postoperative lymphatic leakage in the groin: a video article and literature review.

Inguinofemoral lymphoceles are a common postoperative complication after inguinofemoral lymphadenectomy (LNE) and a challenge for patients as well as physicians. We report here our preliminary experience in the surgical management of a recurrent lymphocele using indocyanine green (ICG) detection, followed by robotic-assisted closure of the lymphatic leaks. The aim of this article is to illustrate the surgical steps of ICG-assisted detection of inguinal lymphatic leaks and their surgical treatment by means of robot-assisted suturing. Furthermore, the feasibility of the approach will be evaluated. A 59-year-old woman with locally advanced squamous cell carcinoma of the vulva and previous conventional bilateral inguinofemoral LNE presented with symptomatic therapy-resistant lymphoceles in the groin. After a lengthy and frustrating course of standard therapy, she was offered the off-label option surgical treatment with ICG detection and subsequent robot-assisted ligation of the leaks, using the Da Vinci robotic system™. Perioperative data, specific aspects of the surgical approach specifics, objective and subjective outcomes of the new approach. The procedure was performed as planned, with no intraoperative complications or device-related issues. The postoperative course was uneventful, and the patient developed no further lymphoceles. Visualisation of the leakage by ICG combined with minimally invasive robotic-assisted laparoscopy is a promising therapy option. The pictures and videos demonstrate our experience in regard of the safety, feasibility, and usefulness of this procedure. Further studies will be needed, to prove the absolute efficacy of the technique and express a general recommendation in regard of this approach for the treatment of inguinofemoral lymphoceles.

Vascularized Omentum Lymphatic Transplantation as a Treatment for Chronic Inguinal Ulceration and Lymphedema.

After tumor resection, lymphadenectomy, and radiotherapy, recurrent lymphatic fluid leakage and infection can occur in the inguinal region, contributing to severe localized tissue fibrosis. When wounds form in this region, they tend to heal slowly over extended periods, and no optimal approach for treating these complex wounds has yet been established. Groin wound debridement and dissection of the vessels in the wound recipient site were performed by the burn surgeon. A general surgeon performed the laparoscopic partial omentum excision. One portion of the omentum was used to fill the large inguinal space, whereas the other portion was laid flat on the wound sites in the groin and anterior perineum to facilitate the restoration of appropriate lymphatic fluid reflux. The vessels of the omentum were microsurgically anastomosed with the vessels in the recipient site. Thin split-thickness slices of skin were then taken from this donor site based on the size of the wound. After the successful establishment of revascularization between the flap and recipient sites, lymphatic fluid leakage was not observed in this patient. No inguinal wounding or lymphatic exudate were evident in the patient during follow-up, and significant improvements in lymphedema of the lower extremities were evident. In this article, we discuss the advantages and disadvantages of vascularized omentum lymphatic transplantation. Overall, this procedure represents a promising new approach for the treatment of refractory wounds caused by lymphatic fistulas.

Indocyanine Green Lymphography-guided Lymphatic Vessel Suture Ligation for Superficial Abdominal Flap Donor Site for Breast Reconstruction.

Autologous breast reconstruction using the abdominal flap based on the superficial system has the potential to minimize donor-site morbidity. Although efforts to improve its transfer have been focused, there have been scarce attempts to further reduce donor-site complications in the abdomen. Seroma formation is a significant complication after the superficial based abdominal flap harvest. The authors report our novel technique to address this issue. Using indocyanine green (ICG) lymphography, we identified lymphatic leakage sites in the abdominal donor site and repaired them by selective suture: ICG-guided lymphatic vessel suture ligation (ICG-LVSL). We performed ICG-LVSL for 10 patients who underwent breast reconstruction using the superficial abdominal flap and compared the incidence of seroma development between ICG-LVSL and non-LVSL groups. After propensity score matching, nine patients remained in each group. The ICG-LVSL group experienced lower incidence of seroma formation (0 versus 55%, P <0.01). The ICG-LVSL technique may be useful for reducing donor-site morbidity of the superficial abdominal flap.

PA-MSHA improves prognosis of patients undergoing radical cystectomy: a retrospective cohort study using inverse probability of treatment weighting.

To observe the effect of Pseudomonas aeruginosa mannose-sensitive hemagglutinin (PA-MSHA) on the prognosis and the incidence of lymphatic leakage in patients undergoing radical cystectomy (RC). A total of 129 patients who underwent RC in Lanzhou University Second Hospital from 2013 to 2022 were enrolled in this study. They were divided into 43 patients treated with PA-MSHA and 86 patients in the control group. Inverse probability of treatment weighting (IPTW) was applied to reduce potential selection bias. Kaplan-Meier method and Cox regression analysis were used to analyze the effect of PA-MSHA on the survival of patients and the incidence of postoperative lymphatic leakage. The PA-MSHA group exhibited improved overall survival (OS) and cancer-specific survival (CSS) rates compared to the control group. The 3-year and 5-year overall survival (OS) rates for the PA-MSHA group were 69.1% and 53.2%, respectively, compared to 55.6% and 45.3% for the control group (Log-rank=3.218, P=0.072). The 3-year and 5-year cancer-specific survival (CSS) rates for the PA-MSHA group were 73.3% and 56.5%, respectively, compared to 58.0% and 47.3% for the control group (Log-rank=3.218, P=0.072). Additionally, the 3-year and 5-year progression-free survival (PFS) rates for the PA-MSHA group were 74.4% and 56.8%, respectively, compared to 57.1% and 52.2% for the control group (Log-rank=2.016, P=0.156). Multivariate Cox regression analysis indicates that lymph node metastasis and distant metastasis are poor prognostic factors for patients, while the use of PA-MSHA can improve patients' OS (HR: 0.547, 95%CI: 0.304-0.983, P=0.044), PFS (HR: 0.469, 95%CI: 0.229-0.959, P=0.038) and CSS (HR: 0.484, 95%CI: 0.257-0.908, P=0.024). The same trend was observed in the cohort After IPTW adjustment. Although there was no significant difference in the incidence of postoperative lymphatic leakage [18.6% (8/35) vs. 15.1% (84.9%), P=0.613] and pelvic drainage volume [470 (440) ml vs. 462.5 (430) ml, P=0.814] between PA-MSHA group and control group, PA-MSHA could shorten the median retention time of drainage tube (7.0 d vs 9.0 d) (P=0.021). PA-MSHA may improve radical cystectomy in patients with OS, PFS, and CSS, shorten the pelvic drainage tube retention time.

Indocyanine green near-infrared fluorescence-assisted video endoscopic inguinal lymph node dissection for rectal cancer: a single-center experience.

This study aimed to investigate the safety and feasibility of indocyanine green near-infrared fluorescence (ICG-NIR) fluorescence-guided video-endoscopic inguinal lymphadenectomy (VEIL) for rectal cancer with inguinal lymph node metastasis (ILNM). A retrospective analysis was conducted on 11 patients with rectal cancer who underwent ICG-NIR fluorescence-guided VEIL, assessing various parameters such as operation time, intraoperative bleeding, number of harvested lymph nodes, intraoperative and postoperative complications, and follow-up. Regarding surgical procedures for ILNM, unilateral surgery was performed in 7 cases (54.5%) and bilateral surgery in 4 cases (45.5%). Among these 15 ICG-NIR-guided VEIL surgeries in 11 patients, positive fluorescence visualization was achieved in 13 operations (86.7%). The median estimated blood loss was 10ml, and the median operation time was 90min. One case (6.7%) required conversion to open surgery. The median duration of the drain tube was 12days, and the median length of postoperative hospital stay was 20days. Postoperative complications were observed, including incisional infection in 2 cases (18.2%), lymphatic leakage in 5 cases (45.5%), urinary infection in 1 case (9.1%), and pneumonia in 3 cases (27.3%). Complications such as skin necrosis, lower limb venous thrombosis, lower limb swelling, or impaired movement were observed during the postoperative follow-up period. No cases of primary lesion, groin, or pelvic lymph node recurrence were observed. ICG-NIR fluorescence-guided VEIL is a safe and feasible surgical treatment for rectal cancer with ILNM. ICG fluorescence guidance holds promise as a more personalized and precise approach for VEIL in rectal cancer surgery.

ABORD ANTEROLATERAL DE LA CHARNIERE THORACO-LOMBAIRE : EXPERIENCE D’UN CAS AVEC CHYLOTHORAX PAR PLAIE IATROGENE DU CANAL THORACIQUE.

Despite its advantages, the anterolateral approach to the thoracolumbar spine can present several complications including chylothorax. We present a rare case of thoracic duct injury secondary to an anterolateral surgical approach to the thoracolumbar spine post-vertebromedullary trauma which was successfully treated non-surgically. Observation: This is a 35-year-old patient, hospitalized for the treatment of a spinal trauma whose radiological assessment revealed a type A3 fracture of the 12th thoracic vertebra according to the Ao-spine classification. He had benefited from a corpectomy of the same vertebra followed by the placement of an interbody implant via an anterolateral approach with thoraco-phrenotomy. The immediate aftermath of the operation was marked by the presence in the chest drain of a white lactescent liquid, the chemical study of which revealed the presence of chylomicrons by electrophoresis, lipoproteins and a triglyceride level of 80 g/l, confirming the diagnosis of chylothorax. Conservative medical treatment was instituted consisting of chest drainage for 3 weeks and parenteral nutrition which allowed complete recovery. Conclusion: Iatrogenic chylothorax represents a rare cause of pleural effusion. This case reflects a successful approach to the management of post-dorsal spine surgery lymph leak via anterolateral approach, using drainage and strict dietary changes, which precluded the need for thoracic duct repair surgery. Keywords: Anterolateral approach, Chylothorax, Conservative treatment,