Lymphatic Complications Research Articles

Increasing Morbidity with Extent of Lymphadenectomy for Primary Malignant Melanoma.

According to current guidelines, complete lymphadenectomy (LAD) is indicated in melanoma patients with a positive sentinel lymph node. Whereas there is little evidence from randomized trials for a survival benefit of this procedure, its morbidity is not trivial. We aimed to assess clinical associations between risk factors and complications of LAD to guide decision making about this aspect of melanoma management. A cohort of 174 patients who had undergone LAD for primary melanoma was retrospectively analyzed, and multivariable logistic regression models were used to correlate patient risk factors, tumor characteristics, number of excised lymph nodes, and procedural details with the incidence of complications. The overall rate of LAD-associated complications was 41.4%, 33.9% being lymphatic complications. The number of excised lymph nodes was independently associated with development of lymphatic complications (odds ratio 3.90/12.78 if more than 10/20 lymph nodes had been removed, p = 0.01/<0.001, respectively). However, the number of excised lymph nodes had no influence on overall survival using a multivariable Cox proportional hazards regression analysis. In this retrospective cohort study, an important association was found between the extent of LAD and lymphatic complications. Further studies should evaluate the necessity and extent of aggressive LAD to balance survival benefit with morbidity of LAD procedures.

Chyluria and chylothorax after posterior selective fusion for adolescent idiopathic scoliosis.

To describe and discuss the diagnostic and treatment complexity of lymphatic system complications after scoliosis surgery. Surgery for adolescent idiopathic scoliosis is very commonly performed with posterior pedicle screw instrumentation. Complications of the anteriorly based lymphatic system are, therefore, rare. We present a case with complications related to the lymphatic system, which have not been reported before after this type of surgery. After standard Th3 to Th12 posterior spinal reduction and fusion of a moderate thoracic curve, chyluria and a chylothorax developed in an adolescent girl. This appeared to be caused by an obstruction of the thoracic duct. Thorax drainage and finally thoracoscopic intervention prevented further pulmonal impairment. The exact cause could not be identified and the persistent lymph drainage problems had to be treated with a medium chain triglyceride diet. With this report, we aim to create awareness of the lymphatic system in general and the possibility of severe complications, even after a posterior only approach of the vertebral column.

A review of the postoperative lymphatic leakage.

Lymphatic complications are rare, but well-known phenomena, and have been described by many researchers. However, many diagnoses of lymphatic complications are found confusing due to different definition. A literature search in Pubmed was performed for studies postoperative lympatic complications. These complications divided into two parts: lymphatic leakage and lymphatic stasis. This review is about lymphatic leakage, especially, postoperative lymphatic leakage due to the injury of lymphatic channels in surgical procedures. According to polytrophic consequences, many types of postoperative lymphatic leakage have been presented, including lymph ascites, lymphocele, lymphorrhea, lymphatic fistula, chylous ascites, chylothorax, chyloretroperitoneum and chylorrhea. In this review, we focus on the definition, incidence and treatment about most of these forms of lymphatic complications to depict a comprehensive view of postoperative lymphatic leakage. We hold the idea that the method of treatment should be individual and personal according to manifestation and tolerance of patient. Meanwhile, conservative treatment is suitable and should be considered first.

Modern lymphatic dissection techniques for preventing post renal transplant lymphocele.

Background and aimsDevelopment of a lymphocele is a well-known complication following kidney transplant. Among causative factors, recipient iliac lymphatics dissection plays an important role. Electrothermal bipolar sealing devices (LigaSureTM) have been shown to decrease lymphatic leakage in a number of instances. The aim of this study was to investigate whether the use of this device decreases post-operative lymphatic complications in kidney transplant.Methods48 patients admitted for renal transplant were included in the study. They were randomly assigned to either conventional ligation or LigaSureTM during lymphatic dissection.ResultsOne patient in the LigaSureTM arm and 5 patients in the conventional ligation arm developed lymphocele (p=0.04). Lymphatic drainage volumes were 99.8±39.87 ml in the LigaSure arm and 131.46±54.2 ml in the conventional ligation arm (p=0.02)ConclusionElectrothermal bipolar sealing devices exhibit safety and efficiency when used in renal transplant lymphatic dissection. In the present study, this technique proved to be superior to conventional ligation in terms of post-operative lymphatic complications.

Prevention of Lymphatic Complications After Laparoscopic Pelvic Lymphadenectomy for Gynecologic Malignancies

Pelvic lymphadenectomy (PLA) is essential for staging and treatment of different gynecologic malignancies as cervical, endometrial, or ovarian cancers. However, PLA can induce lymphatic complications as pelvic lymphoceles or lymphedemas in a considerable percentage of patients. The proper strategy to reduce lymphatic complications has not established yet.

Congenital heart defects in Noonan syndrome and RIT1 mutation

To the Editor: We read with great interest the article by Kouz et al.1.Kouz K, Lissewski C, Spranger S, et al. Genotype and phenotype in patients with Noonan syndrome and a RIT1 mutation. Genet Med e-pub ahead of print 21 April, 2016.Google Scholar reporting on genotype–phenotype correlations of patients with Noonan syndrome (NS) heterozygous for RIT1 mutations. The authors performed an exhaustive analysis of the features associated with mutations in this gene, which was recently described as a new causative gene for the syndrome and accounts for approximately 5–10% of the total cases of NS cases. Cardiac and extracardiac features of this new subset of patients were discussed by Kouz et al.,1.Kouz K, Lissewski C, Spranger S, et al. Genotype and phenotype in patients with Noonan syndrome and a RIT1 mutation. Genet Med e-pub ahead of print 21 April, 2016.Google Scholar and clinical characteristics of patients with RIT1 mutation were compared to those found in patients with mutations in other genes known to be related to RASopathies. We report here a few additional details regarding the cardiac phenotype in this subgroup of patients. Among our series of 161 patients with a molecularly confirmed diagnosis of RASopathy, 9 patients (6%) with a clinical diagnosis of NS carrying a missense RIT1 mutation were recently identified. Congenital heart defects in this subgroup of patients are seen in 100% of patients, which is in line with the data reported by Kouz et al.1.Kouz K, Lissewski C, Spranger S, et al. Genotype and phenotype in patients with Noonan syndrome and a RIT1 mutation. Genet Med e-pub ahead of print 21 April, 2016.Google Scholar Consistent with the published data, pulmonary valve stenosis, hypertrophic cardiomyopathy (HCM), atrial septal defect (ASD), and ventricular septal defect (VSD) were reported in our subjects with RIT1 mutations. One patient in our cohort had partial atrioventricular canal defect (pAVCD). Four patients in our series presented HCM. Two of them had an obstructive HCM (oHCM), which was associated with subaortic stenosis and pulmonary valve stenosis in one patient who required an orthotopic heart transplant during the first year of life due to the severity of the cardiac phenotype, which was unresponsive to extensive medical treatment. These data confirm what was previously reported by Colan et al.,2.Colan S.D. Lipshultz S.E. Lowe A.M. Epidemiology and cause-specific outcome of hypertrophic cardiomyopathy in children: findings from the Pediatric Cardiomyopathy Registry.10.1161/CIRCULATIONAHA.106.621185Circulation. 2007; 115: 773-781Google Scholar as well as our unpublished data, documenting that patients with an early-onset HCM phenotype (younger than 2 years of age), particularly in cases of biventricular obstructions, have poor prognoses. Based on these considerations, HCM in NS subjects with a RIT1 gene mutation should be carefully evaluated, particularly if it occurs in early childhood. Four patients had pulmonary valve stenosis with a typical thickened and dysplastic valve. The supravalvular region was involved in the lesion in all of them, as generally reported in NS. To the best of our knowledge, our patient with pAVCD is the first diagnosed with RIT1 mutation. This observation confirms the high prevalence of AVCD previously noted in RASopathies and not only in association with PTPN11 and RAF1 mutations.3.Digilio M.C. Romana Lepri F. Dentici M.L. Atrioventricular canal defect in patients with RASopathies.1:CAS:528:DC%2BC3sXht1Cks7s%3D10.1038/ejhg.2012.145Eur J Hum Genet. 2013; 21: 200-204Google Scholar Finally, lymphatic anomalies were present in three out of the nine patients in our cohort, including chylothorax in two subjects and lymphedema of the lower limbs in one. Chylothorax was persistent in both children and required postoperative drainage. These data confirm the relevant role of RIT1 mutations in early-onset and late-onset lymphatic complications, which could lead to significant postoperative morbidity in these subjects. In conclusion, the prevalence of congenital heart defects in patients carrying heterozygous RIT1 mutations is high and a great variety of anatomic types can be observed, including HCM, which can be particularly severe. Finally, complications due to lymphatic anomalies should also be taken into consideration. The authors declare no conflict of interest.

Effect of Fibrin Glue on the Incidence of Surgical Complications After Living-Related-Donor Kidney Transplantation: Results of a Randomized Clinical Trial.

BACKGROUND The incidence of surgical complications after kidney transplantation ranges from 10-25%. The purpose of this study was to evaluate if the application of fibrin glue as a preventive agent reduces surgical morbidity after a living-related-donor kidney transplantation. MATERIAL AND METHODS A controlled clinical trial involving 78 recipients randomly assigned to receive fibrin glue and 79 in the control group without the application of fibrin glue. Patients were followed for six months after surgery. RESULTS The average ages were 24.8±9.4 and 27.4±11.3 years in the control and study groups, respectively (p=0.11). Individual morbidities, such as urologic, lymphatic, vascular, and wound complications, were not statistically different between groups; however, the total number of surgical complications observed were in five patients in the study group and 16 patients in the control group. This difference was statistically significant (p<0.01, relative risk 0.44, 95% CI 0.20-0.97). There was no mortality or adverse reaction to fibrin glue. One kidney graft was lost because of uncontrollable bleeding secondary to tearing of the renal capsule. The incidence of early medical complications was similar between groups. CONCLUSIONS Applications of the biological adhesive reduced the incidence of surgical complications.

Fibro-Lipo-Lymph-Aspiration With a Lymph Vessel Sparing Procedure to Treat Advanced Lymphedema After Multiple Lymphatic-Venous Anastomoses: The Complete Treatment Protocol.

In lymphedema, excess adipose tissue occurs with progression of the disease because of chronic lymph stasis, impeding lymphatic flow. Recently, liposuction has been used as a less-invasive procedure to remove this excess tissue. Given the existing poor lymph drainage in patients with lymphatic diseases, extra caution should be taken to avoid damaging lymphatic vessels during liposuction. We developed a new technique (Fibro-Lipo-Lymph-Aspiration with a Lymph Vessel Sparing Procedure [FLLA-LVSP]) to improve chronic swelling in patients with advanced lymphedema. The FLLA-LSVP highlights the superficial lymphatic pathways in the treated limb. This visibility allows surgeons to avoid these pathways, while removing the maximum amount of excess tissue. One hundred forty-six patients with primary or secondary lymphedema that had already been treated by lymphatic microsurgery, in Genoa, Italy, were included in this retrospective study. All patients had residual fibrotic/adipose tissue, resistant to conservative treatments. Indocyanine green fluorescent dye and Blue Patent Violet dye were injected laterally/medially to the main superficial veins at the wrist/ankle of the limb to be treated. Using a photodynamic camera, the superficial lymphatic network was made visible and sketched onto the skin in indelible ink. After the microlymphography, the excess adipose tissue was carefully aspirated. Preoperative and postoperative excess limb volume was calculated using circumferential measurements and the formula of a frustum. For the upper limb, 0.80 L, on average, and 2.42 L for the lower limb were removed with the FLLA-LVSP. For the upper limb, there was an average presurgery excess volume of 20.19%, which reduced to 2.68% after the FLLA-LVSP (Z score = -6.90, P < 0.001). Similarly, for the lower limb, there was an average presurgery excess limb volume of 21.24% and a reduction to 2.64% postoperatively (Z score = -3.57, P < 0.01). Immediate postoperative microlymphography and Blue Patent Violet test confirmed no lymphatic complications. No episodes of postoperative infection occurred. The FLLA-LVSP is efficient. An entire leg can be completed within 90 minutes. Recovery time is short, and cosmetic results are immediate. More importantly, the removal of excess tissue is completed without further damage to lymphatic vessels. When used after microsurgery, FLLA-LVSP offers the possibility of removing almost all obstacles to lymphatic flow.

Intraoperative optical coherence tomography for assessing human lymph nodes for metastatic cancer.

BackgroundEvaluation of lymph node (LN) status is an important factor for detecting metastasis and thereby staging breast cancer. Currently utilized clinical techniques involve the surgical disruption and resection of lymphatic structure, whether nodes or axillary contents, for histological examination. While reasonably effective at detection of macrometastasis, the majority of the resected lymph nodes are histologically negative. Improvements need to be made to better detect micrometastasis, minimize or eliminate lymphatic disruption complications, and provide immediate and accurate intraoperative feedback for in vivo cancer staging to better guide surgery.MethodsWe evaluated the use of optical coherence tomography (OCT), a high-resolution, real-time, label-free imaging modality for the intraoperative assessment of human LNs for metastatic disease in patients with breast cancer. We assessed the sensitivity and specificity of double-blinded trained readers who analyzed intraoperative OCT LN images for presence of metastatic disease, using co-registered post-operative histopathology as the gold standard.ResultsOur results suggest that intraoperative OCT examination of LNs is an appropriate real-time, label-free, non-destructive alternative to frozen-section analysis, potentially offering faster interpretation and results to empower superior intraoperative decision-making.ConclusionsIntraoperative OCT has strong potential to supplement current post-operative histopathology with real-time in situ assessment of LNs to preserve both non-cancerous nodes and their lymphatic vessels, and thus reduce the associated risks and complications from surgical disruption of lymphoid structures following biopsy.

The contribution of a collagen–fibrin patch (Tachosil) to prevent the postoperative lymphatic complications after groin lymphadenectomy: a double institution observational study

ObjectivePostoperative morbidity associated with groin lymphadenectomy remain high and still represents a major concern for this patients. The aim of this study was to confirm the efficacy of TachoSil® in preventing postoperative complications after inguinofemoral lymphadenectomy for gynecological malignancy. Study designAn observational study was conducted to evaluate the incidence of postoperative complications among 49 patients (TachoSil® group=24; control group=25) underwent groin dissection enrolled in two Italian Department of Gynecology Oncology from 2011 to 2014. ResultsA total of 74 inguinal dissections were performed. Bilateral groin dissection was performed in 25 patients (Tachosil group=10; group 2=15). Patients in TachoSil® group showed a lower daily drainage volume with a mean volume of 84ml (range 30–465) vs. 143ml (range −72 to 413) in the control group (p=.004), and a lower total drainage volume with a mean of 540ml (range 90–930) vs. 900ml (range 200–3270) for Tachosil and control group, respectively. A lower incidence of lymphocyst required drainage, cellulitis, wound infection and late lymphedema was observed in TachoSil group even without reaching statistical significance. ConclusionsThis observational study confirmed that the use of TachoSil® seems to be highly effective in reducing the rate of postoperative lymphorrea and postoperative complications after groin dissection in case of gynecological malignancies. Larger multicenter prospective study is advisable to validate our preliminary results.

Robotic infrarenal paraaortic and pelvic nodal staging for endometrial cancer: feasibility and lymphatic complications.

This study was designed to evaluate the feasibility and lymphatic complications of robotic pelvic and infrarenal paraaortic lymphadenectomy in endometrial cancer patients. All patients diagnosed with high risk endometrial cancer during the study period were identified (n = 212). Clinical prospective data, with reassessment of lymphatic complications, was analysed for all cases (n = 140) planned for a complete robotic nodal staging. The outcome measures were: success rate of infrarenal paraaortic lymphadenectomy, the rate of lymphatic complications and factors associated with nodal yield. Of the 212 women, an open or restricted robotic procedure was performed in 57 women (27%) and no operation in 15 (7%), the latter due to disseminated disease or comorbidity. In 140 women (66%) in whom staging was intended, the lymphadenectomy included the infrarenal area in 70%, was restricted to the inframesenteric area in 21% and aborted or incomplete in 9%. The median number of paraaortic nodes was 10 (range 2-39). An unsuccessful staging was associated with high BMI and the surgeon's inexperience. At 1 year, three patients (2%) had developed a grade two lower limb lymphedema. Eleven women (8%) demonstrated pelvic lymphocysts; seven (64%) resolved spontaneously. Only one paraaortic lymphocyst was found; this required drainage. No cases of chylous ascites occurred. An infrarenal robotic paraaortic lymphadenectomy is feasible in 70% of high risk endometrial cancer cases when intended (88% in non-obese patients operated by experienced surgeons), but is restricted in obese patients and by surgeon's inexperience.

Ultrasonic Technology Decreases Wound Complications in Groin Dissection for Vascular Procedures

Methods: A retrospective analysis of prospectively collected data from a single institution (Stony Brook University Medical Center) using the Vascular Quality Initiative database was performed. The research protocol was defined prior to initiating data collection. Included were consecutive pa- tients who underwent groin dissection with either electrocautery (group A) or ultrasonic devices (group B) during the following procedures: endovascu- lar aortic aneurysm repair, thoracic endovascular aortic aneurysm repair, lower extremity bypass, or hybrid peripheral vascular intervention. In-hospi- tal and outpatient records were reviewed to capture postoperative surgical site complications, and clinical outcomes were compared between the groups. Results: Over a 24-month period, 233 patients underwent peripheral vascular interventions that required 346 groin dissections. There were no significant differences in the risk profile of the patients between group A (n ¼ 135) and group B (n ¼ 98). Wound complications (hematoma, infec- tion, dehiscence, lymphocutaneous fistula, and seroma/lymphocele) occurred significantly less often in the ultrasonic group (group B: 7.2%) compared with the electrocautery group (group A: 28.5%; P < .0001). When looking at specific wound complications, use of the ultrasonic energy device significantly decreased the rate of lymphatic complications (2.1% vs 14.6%; P < .01) and wound dehiscence (0% vs 7%; P ¼ .01). Conclusions: The use of the ultrasonic energy device (Harmonic), when compared with electrocautery (Bovie) in surgical dissection of the groin, is associated with a lower rate of wound complications, specifically lymphatic leaks and wound dehiscence. Routine use of this alternative tool may help decrease surgical site complications in this particularly vulner- able area.

Lymphatic disorders after renal transplantation: new insights for an old complication.

In renal transplanted patients, lymphoceles and lymphorrhea are well-known lymphatic complications. Surgical damage of the lymphatics of the graft during the procurement and of the lymphatic around the iliac vessels of the recipients has been associated with development of lymphatic complications. However, lymphatic complications may be related to medical factors such as diabetes, obesity, blood coagulation abnormalities, anticoagulation prophylaxis, high dose of diuretics, delay in graft function and immunosuppressive drugs. Consistently, immunosuppression regimens based on the use of mTOR inhibitors, especially in association with steroids and immediately after transplantation, has been associated with a high risk to develop lymphocele or lymphorrhea. In addition, several studies have demonstrated the association between rejection episodes and lymphatic complications. However, before the discovery of reliable markers of lymphatic vessels, the pathogenic mechanisms underlining the development of lymphatic complications during rejection and the influence of mTOR inhibitors remained not fully understood. The recent findings on the lymphatic systems of either native or transplanted kidneys together with the advances achieved on lymphangiogenesis shared some lights on the pathogenesis of lymphatic complications after renal transplantation. In this review, we describe the surgical and medical causes of lymphatic complications focusing on the rejection and immunosuppressive drugs as causes of lymphatic complications.

V8-09 ROBOTIC-ASSISTED INGUINAL LYMPHADENECTOMY: EARLY OUTCOMES AND TECHNICAL MODIFICATIONS

You have accessJournal of UrologyBladder Oncology/Testis/Transplantation/Trauma1 Apr 2015V8-09 ROBOTIC-ASSISTED INGUINAL LYMPHADENECTOMY: EARLY OUTCOMES AND TECHNICAL MODIFICATIONS Alexander M. Helfand, Jeffrey S. Montgomery, Alon Z. Weizer, and Todd M. Morgan Alexander M. HelfandAlexander M. Helfand More articles by this author , Jeffrey S. MontgomeryJeffrey S. Montgomery More articles by this author , Alon Z. WeizerAlon Z. Weizer More articles by this author , and Todd M. MorganTodd M. Morgan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2133AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Penile cancer with nodal metastases is associated with poor cancer-specific survival. Both resection of metastatic nodes and prophylactic removal of benign nodes provide durable survival advantages. Open inguinal lymph node dissection (ILND) is associated with a high rate of cutaneous and lymphatic complications, particularly skin flap necrosis. Endoscopic ILND prevents iatrogenic disruption of the inguinal skin's vascular supply, thus reducing the incidence of major complications. Our objective is to use video to describe our robotic-assisted inguinal lymphadenectomy (RAIL) technique and report early outcomes in both clinically node-negative and positive patients. METHODS We conducted 10 RAIL procedures in 6 patients with invasive penile squamous cell carcinoma from 2013-2014. Four patients received bilateral RAIL in the same setting and two had unilateral RAIL after contralateral open ILND. We stationed the robotic base directly over the midline at the patient's head and put the patient in moderate Trendelenburg to eliminate the need for intraoperative repositioning. The median post-operative follow-up period was 87 days (17-511). We classified complications as early (≤30 days) or late (31-90 days) and graded them by the Clavien Dindo classification system. RESULTS In our cohort, median age was 74.7 years (IQR 73-79), Charlson comorbidity index was 6 (5-12), and BMI was 36.1 kg/m2 (29-42). Per limb, median operative time was 157.5 minutes (137-182), blood loss was 25 mL (8-25), superficial nodal yield was 8 nodes (6-11), and time to drain removal was 24.5 days (20-27). There were no intraoperative complications. Median length of stay was 2 days (2-4). Two patients with clinically node-positive cancer had bilateral metastatic nodes (1.5 per limb (1-3)). All other patients had pN0 cancer. Clavien I-II complications occurred in 4 patients in 6 limbs (seroma, wound infection). One patient had a seroma requiring operative drainage (Clavien III). Early complications occurred in 6 limbs, and there was a late complication (seroma) in 1 limb. In follow-up, 2 patients had locoregional recurrence (1 died), and 1 had lung metastases. CONCLUSIONS RAIL is a safe procedure with similar nodal yield to open ILND, no intraoperative complications, and technical advantages for the surgeon. Postoperative complications are mostly minor and no skin flap necrosis was seen, yet surgical site complications remain problematic. Reducing the morbidity of RAIL and proving oncological efficacy will require continued investigation. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e717-e718 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alexander M. Helfand More articles by this author Jeffrey S. Montgomery More articles by this author Alon Z. Weizer More articles by this author Todd M. Morgan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Utility of Electrofusion for the Femoral Approach in Vascular Surgery: A Randomized Prospective Study

The local complications are frequent after a femoral approach in vascular surgery and are often the cause of a delay in healing. Electrofusion showed its effectiveness to decrease the complications in general surgery but was not tested in vascular surgery. The aim of our study was to evaluate if the use of electrofusion in the approach to femoral vessels improved healing at 1month by decreasing the local complications. This prospective randomized study was conducted in 2 centers from May 1, 2012 to April 30, 2013. All the patients requiring a surgical access of the femoral trigone were included in 2 French teaching hospitals. Femoral artery surgical exposure was carried out using electrofusion or according to the conventional technique (diathermy or cold scalpel) according to a protocol of randomization. The principle criterion of the study was a complete healing at 1month. The secondary criteria were the appearance of cutaneous, infectious, or lymphatic local complications. Two hundred ninety-two femoral approaches were carried out in 221 consecutive patients. One hundred forty-eight approaches were carried out with electrofusion and 144 according to the conventional technique. The demographic and operative characteristics were similar between the 2 groups. At 1month, 86.3% of the approaches were healed without statistically significant difference between the 2 groups (88.5% vs. 84%, P=0.241). There were less local complications (P=0.012) and seromas (P=0.012) in the electrofusion group. This difference could be linked with the least quantities (P=0.036) and durations (P=0.014) of drainage observed after approaches carried out with electrofusion. On the other hand, the incidence of cutaneous or infectious complications was not different between the 2 groups. In our series, the use of electrofusion decreased the lymphatic complications after a femoral approach. However, the correction of this single parameter was not sufficient to improve the rate of healing at 1month.

Evaluation of lymphangiogenesis in acellular dermal matrix.

Introduction:Much attention has been directed towards understanding the phenomena of angiogenesis and lymphangiogenesis in wound healing. Thanks to the manifold dermal substitute available nowadays, wound treatment has improved greatly. Many studies have been published about angiogenesis and cell invasion in INTEGRA®. On the other hand, the development of the lymphatic network in acellular dermal matrix (ADM) is a more obscure matter. In this article, we aim to characterize the different phases of host cell invasion in ADM. Special attention was given to lymphangiogenic aspects.Materials and Methods:Among 57 rats selected to analyse the role of ADM in lymphangiogenesis, we created four groups. We performed an excision procedure on both thighs of these rats: On the left one we did not perform any action except repairing the borders of the wound; while on the right one we used INTEGRA® implant. The excision biopsy was performed at four different times: First group after 7 days, second after 14 days, third after 21 days and fourth after 28 days. For our microscopic evaluation, we used the classical staining technique of haematoxylin and eosin and a semi-quantitative method in order to evaluate cellularity counts. To assess angiogenesis and lymphangiogenesis development we employed PROX-1 Ab and CD31/PECAM for immunohistochemical analysis.Results:We found remarkable wound contraction in defects that healed by secondary intention while minor wound contraction was observed in defects treated with ADM. At day 7, optical microscopy revealed a more plentiful cellularity in the granulation tissue compared with the dermal regeneration matrix. The immunohistochemical process highlighted vascular and lymphatic cells in both groups. After 14 days a high grade of fibrosis was noticeable in the non-treated group. At day 21, both lymphatic and vascular endothelial cells were better developed in the group with a dermal matrix application. At day 28, lymphatic endothelial cells had organized themselves, engineering the pseudocylindrical structure better disposed in the ADM group than in the control group, and the lymphatic cells were detectable inside the vessels’ lumen in this group.Conclusion:This study has made it possible to demonstrate the absolute importance of an ADM in proper wound healing and has shown better definition of both the qualitative and quantitative aspects of lymphangiogenesis compared to the second intention healing. A major grade of organization of the extracellular matrix and a minor grade of fibrosclerosis in ADM allowed a well-structured morphologic and functional development of the endothelial and lymphatic vascular structures. This study hopes to represent a clinical basis for a wider use of ADM in lesions where lymphatic complications are common.

Method for the quantitative measurement of collecting lymphatic vessel contraction in mice.

Collecting lymphatic vessels are critical for the transport of lymph and its cellular contents to lymph nodes for both immune surveillance and the maintenance of tissue-fluid balance. Collecting lymphatic vessels drive lymph flow by autonomous contraction of smooth muscle cells that cover these vessels. Here we describe methods using intravital microscopy to image and quantify collecting lymphatic vessel contraction in mice. Our methods allow for the measurement of the strength of lymphatic contraction of an individual lymphangion in a mouse, which has not yet been demonstrated using other published methods. The ability to study murine collecting lymphatic vessel contraction-using the methods described here or other recently published techniques-allows the field to dissect the molecular mechanisms controlling lymphatic pumping under normal and pathological conditions using the wide variety of molecular tools and genetic models available in the mouse. We have used our methods to study lymphatic contraction in physiological and inflammatory conditions. The methods described here will facilitate the further study of lymphatic function in other pathological conditions that feature lymphatic complications.

Lymphatic complications after vascular interventions.

IntroductionLymphorrhea due to classical and mini-invasive surgical interventions on femoral and popliteal arteries is a serious hindrance to patient treatment. Depending on the experience of a particular center, the incidence and frequency of this type of complication may constitute a serious clinical problem. While the level of lymphorrhea intensity and its duration result in certain foreseeable consequences, their treatment can be a time-consuming and multistep procedure.AimTo compare different types of vascular interventions with lymphorrhea occurrence.Material and methodsThe authors conducted a retrospective analysis of lymphatic complications based on the material collected between 2005 and 2012 at the Department of Vascular and Endovascular Surgery of the Military Institute of Medicine in Warsaw and in the Department of Interventional Cardiology and Angiology of the Institute of Cardiology in Anin, Warsaw, in 2009–2012.ResultsMaintaining due thoroughness when dissecting tissues and treating the cutting line in this area with ligatures and tissue puncture are the most reliable methods of minimizing the risk of lymphatic leakage after surgical procedures performed in a classical way. The lymphatic complication under analysis is far less likely to occur when procedures are performed as planned and an endovascular technique is used – statistical significance p < 0.05. Minimally invasive and fully percutaneous procedures performed via needle puncture, including the use of the fascial closure technique to close the femoral artery, eliminate the likelihood of the occurrence of this vascular complication – statistical significance was found with p value less than 0.05.ConclusionsWe concluded that in every case by minimizing the vascular approach we protected the patient against lymphatic complications.

MRI of lymphatic abnormalities after functional single-ventricle palliation surgery.

Protein-losing enteropathy (PLE) and plastic bronchitis are serious complications that occur after single-ventricle surgery. A lymphatic cause for these conditions has been proposed, but imaging correlation has not been reported. The objective of this study was to evaluate lymphatic abnormalities in patients after functional single-ventricle palliation compared with patients with non-single-ventricle congenital heart conditions using T2-weighted MR lymphangiography. We retrospectively reviewed imaging data from 48 patients who underwent T2-weighted MR lymphangiography in our institution between May 1, 2012, and October 24, 2012. The patients were divided into four groups: patients who underwent superior cavopulmonary connection, patients who underwent total cavopulmonary connection, patients with total cavopulmonary connection and lymphatic complications, and patients with non-single-ventricle cardiac anomalies. There were 38 patients with single ventricles in this study. The lymphatic abnormalities observed in these patients included thoracic duct dilation greater than 3 mm (31%), lymphangiectasia and lymphatic collateralization (78%), and tissue edema (86%). There were five patients with PLE, one patient with plastic bronchitis, and one patient with chronic chylous effusions and superior cavopulmonary connection. The patients with PLE and plastic bronchitis had statistically significant larger thoracic duct maximal diameters (median, 3.9 mm; range, 3-7.2 mm) than did the other patients with total cavopulmonary connection (p < 0.01). In the two-ventricle patient group, there were no abnormal lymphatic findings. Lymphatic abnormalities are found in many patients after functional single-ventricle palliation. T2-weighted unenhanced MRI is capable of anatomic assessment of the lymphatic system in this patient population and has promise for guiding treatment in the future.

Therapeutic efficacy of vacuum-assisted-closure therapy in the treatment of lymphatic complications following peripheral vascular interventions and surgeries

Lymphatic complications, lymphocele and lymphorrhea being the leading, are generally encountered after vascular interventions and surgeries. The present study aimed to evaluate the outcomes of vacuum-assisted-closure (VAC) therapy, which we frequently prefer as the first-choice treatment for such complications. Among patients undergoing peripheral vascular intervention or surgery between January 2008 and February 2012, the medical files of 21 patients who received VAC therapy or other treatment due to symptomatic lymphatic complications were retrospectively analyzed and the results were discussed. Group I consisted of 10 patients (three with lymphocele and seven with lymphorrhea) who underwent VAC therapy as the first-choice treatment, Group II consisted of 11 patients of which 7 patients received various therapies before VAC therapy and 4 patients received other treatments alone. The patients who received VAC therapy as the primary therapy demonstrated more rapid wound healing, early drainage control, and shorter hospital stay. The mean hospital medical cost was €1038 (range, €739-1826) for the patients who primarily underwent VAC therapy; it was calculated to be €2137 (range, €1610-3130) for the other patients (p=0.001). In addition to its safety and good clinical outcomes, VAC therapy also has economic advantages and should be the primary method for the treatment of lymphatic complications.