Occurrence Of Lymphoceles Research Articles

A Comparative Study of Laparoscopic Extraperitoneal Laparoscopy With the Use of Ultrasonically Activated Shears

Previous studies have demonstrated the efficacy and safety of extraperitoneal laparoscopic lymphadenectomies. The rate of peri- and postoperative complications with these procedures is below 15%. One of the most common postoperative complications, lymphocele, occurs in 3.8% to 21 % of patients, and can be symptomatic or nonsymptomatic. Nonsymptomatic lymphoceles require no treatment. Although the incidence of symptomatic lymphocele has decreased with the use of systematic preventive marsupialization, this procedure does not seal the lymphatic vessels and thus does not prevent lymphatic leakage during lymph nodes dissection. A device employing ultrasonic energy, the ultrasonically activated shears (the harmonic scalpel) has been investigated for management of symptomatic lymphoceles after pelvic lymphadenectomy in patients with gynecological malignancies. This device achieves both coagulation and cutting without instrument exchanges. In a small number of studies, use of the ultrasonic shears has reduced the occurrence of lymphoceles and accomplished sealing, thereby reducing lymphatic leakage. The aim of this study was to investigate the effectiveness of the ultrasonic shears in reducing the occurrence of symptomatic lymphoceles in patients who had undergone para-aortic laparoscopic lymphadenectomies (PALLs) in a prospective setting. The postoperative complications of PALLs were also investigated. A total of 98 patients who had received PALLS were divided into 2 groups. The ultrasonic group was comprised of 36 patients receiving PALLs that were performed with the activated shears. Outcomes in the study group were compared with a historical control group comprised of 62 patients receiving PALLs performed with the standard coagulation procedure. There were no statistically significant differences in the following perioperative and postoperative parameters between the ultrasonic group and control group: Operating time (129.9 ± 38.1 vs. 109.8 ± 38.1 minute, P = 0.22), hospital stay (5.1 ± 2.7 vs. 4.48 ± 3.6 days, P = 0.34), lymph nodes removed (19.8 ± 9.7 vs. 21.1 ± 8.8, P = 0.50) and positive lymph nodes (1.03 ± 2.9 vs. 0.89 ± 2.0, P = 0.78). In addition, no difference in blood loss occurred. No patients in the study group, but 7 patients in the control group experienced symptomatic lymphoceles that required medical treatment (P = 0.03). Four control patients had radiologic drainage and 1 received surgical drainage. The rate of peri/postoperative complications was 9%, which is comparable with rates of PALL reported in major studies. These findings are consistent with those of a number of major studies showing that the ultrasonically activated shears are effective for the performance of PALL. These and previous data suggest to the investigators that combined use of the shears together with systematic preventive marsupialization may significantly lower the frequency of postoperative symptomatic lymphoceles and other complications.

Fifteen Years of Clinical Studies and Clinical Practice in Renal Transplantation: Reviewing Outcomes With De Novo Use of Sirolimus in Combination With Cyclosporine

Over the course of 15 years the use of sirolimus, a macrocyclic lactone, has evolved from an adjunct to calcineurin inhibitors (CNI) to the foundation of therapy due to the drug's unique properties: First, it displays synergistic pharmacodynamic interactions with CNI. Even among high immunologic risk patients, this regimen attenuates the risk of acute allograft rejection episodes when used in combination with cyclosporine or tacrolimus. Indeed >80% reduction in CNI exposure de novo yields better long-term renal function than full cyclosporine (CsA) doses, a useful tradeoff, despite the augmented occurrence of lymphoceles and impaired wound healing. Second, by inhibiting mammalian target of rapamycin (mTOR), it exerts profound anti-neoplastic effects reducing the incidence and mediating the regression of tumors displaying PTEN-deletions and/or Akt-activations in transplant and non-transplant patients. Third, it is relatively non-nephrotoxic although it may exacerbate that property of CNI agents. Fourth, it allows prompt withdrawal of steroid therapy. Fifth, it displays reduced rates of cytomegalovirus, and BK virus infections. The major adverse reactions can generally be controlled with countermeasure therapy. Myelosuppressive effects, which tend to be transient (unless sirolimus is combined with mycophenolic acid), are readily amenable to treatment with granulocyte colony stimulating factor for leukopenia, interleukin 11 for thrombocytopenia and erythropoietin for anemia. Combinations of statins and fibrates represent effective countermeasure therapy for hypercholesterolemia and hypertriglyceridemia, respectively. Idiosyncratic reactions include hypoxemic pulmonary toxicity, refractory edema and diarrhea. Thus, sirolimus represents the vanguard of a new class of maintenance agents for immunosuppression.

Does Opening the Peritoneum at the Time of Renal Transplanation Prevent Lymphocele Formation?

Background The occurrence of lymphocele formation following renal transplantation is variable, and the optimal approach to treatment remains undefined. Opening the peritoneum at the time of transplantation is one method of decreasing the incidence of lymphocele formation. The purpose of this study was to determine whether creating a peritoneal window at the time of transplantation decreases the incidence of lymphocele formation. Methods We performed a retrospective review of renal transplants conducted at our institution between 2002 and 2004. Records were reviewed to obtain details regarding opening of the peritoneum at the time of transplant and occurrence of lymphocele. Every patient underwent routine ultrasound imaging in the peri-operative period. Graft dysfunction secondary to the lymphocele was the primary indication for intervention. Data were analyzed by chi-square. Results During the initial transplant the peritoneum was opened in 35% of patients. The overall incidence of fluid collections, identified by ultrasound, was 24%. Opening the peritoneum did not decrease the incidence of lymphocele. However, more patients with a closed peritoneum required an intervention for a symptomatic lymphocele. In the 11 patients with an open peritoneum and a fluid collection, only one required an intervention. In patients whose peritoneum was left intact, 24% of fluid collections required intervention. Graft survival was equivalent. Conclusion Creating a peritoneal window at the time of transplantation did not decrease the overall incidence of postoperative fluid collections. However, forming a peritoneal window at the time of transplantation did decrease the incidence of symptomatic lymphocele.

Post transplant lymphocele: a single centre experience.

The occurrence of post renal transplant lymphocele is variable and the best approach to treatment is not well defined. The purpose of this study was to find out the incidence of post transplant lymphocele at our centre, identify demographic or surgical factors that may have influenced lymphocele formation, and distinguish the best approach to treatment. The charts of 138 consecutive renal transplant recipients from 1996 to 2001 were retrospectively reviewed. The demographic characteristics, comorbid illnesses, occurrence of lymphocele and its treatment modality were recorded. A total of 36 (26%) patients developed lymphoceles. There was a significant relationship between an increased body mass index (BMI) and lymphocele occurrence (P > 0.01). The recurrence rate with drainage alone was 33%, which decreased to 25% with sclerotherapy. In comparison, both laparoscopic and open surgical marsupialization had a much lower but similar recurrence rate of 12%. The laparoscopic method had less morbidity, a shortened hospital stay, and less infection than open surgery.

An Analysis of the Risk Factors and Management of Lymphocele after Pelvic Lymphadenectomy in Patients with Gynecologic Malignancies

The incidence and risk factors of lymphocele development after pelvic lymphadenectomy were evaluated and its management investigated. This retrospective study was carried out on 264 patients who received a pelvic lymphadenectomy, between March 1999 and February 2003, due to gynecologic cancer. The patients were classified into two groups; the lymphocele (n=50) and non-lymphocele groups (n=214), as confirmed by ultrasonography, CT scan and MRI. Each group was compared by cancer type and stage, BMI, preoperative Hb, use of pre/postoperative chemotherapy or radiotherapy, number of resected pelvic lymph nodes and the volume of postoperative drainage from a Hemovac pelvic drain. Of the 264 patients tested, 15 of 105 cervical cancer (14%), 22 of 115 ovarian cancer (19%) and 11 of 40 endometrial cancer patients (27%), a total of 50 patients (18%), developed lymphoceles. In the lymphocele group (n=50), 13 patients were diagnosed with complicated lymphocele. The BMI and number of resected pelvic lymph nodes were found to be higher in the lymphocele than in the non-lymphocele group (23.94+/-3.38 vs. 22.52+/-3.00, p=0.00 and 26.80+/-14.82 vs. 22.96+/-10.18, p=0.03, respectively), and showed statistical significance. The occurrence of lymphoceles was lower without postoperative radiotherapy (p=0.01). Among the 264 patients, a total of 50 patients (18%) developed lymphoceles. The BMI and number of resected lymph nodes were higher in the lymphocele group, and the use of postoperative radiotherapy was associated with a higher risk of lymphoceles. Thirteen of the 50 patients that developed lymphoceles (n=50) required treatment for lymphocele-related complications.

Prospective evaluation of surgical staging of advanced cervical cancer via a laparoscopic extraperitoneal approach

Purpose To report on a large series of cervical cancer patients at risk for lymph node metastasis who underwent surgical staging by a novel technique. Methods Between 1/97 and 3/02, we identified 111 patients who underwent an infrarenal aortic and common iliac lymph node dissection via a laparoscopic extraperitoneal approach for either bulky or locally advanced cervical cancer. We reviewed the medical records and extracted pertinent information. Results There were no intraoperative complications. Mean patient age was 46 (± 9) years. Mean node count was 19 (± 12). Thirty (27%) patients had lymph node metastasis. The mean operative time was 157 (± 46) min, and mean postoperative stay was 2 days. The majority of complications in the early part of the series were symptomatic lymphoceles. Since 4/01, preventive peritoneal marsupialization has been performed without lymphocele occurrence (37 patients). Two patients (2%) required reoperation. In the node-positive group, extended-field radiation and chemotherapy were well tolerated, but prognosis was dismal (median survival, 27 months). In the node-negative group, the median survival after pelvic radiation limited to the lower level of the surgical dissection was not reached after an average follow-up of 16.6 months. Conclusions This novel technique is feasible and combines the benefits of laparoscopy with those of a retroperitoneal approach. It can be used to tailor external radiation therapy. The benefits of extended-field radiation therapy remain unclear; however, this approach does not preclude later use of radiation therapy, whereas possibly minimizing associated toxicities secondary to adhesions.

Occurrence of lymphoceles after allogeneic kidney transplantation and their therapy

We conducted a prospective evaluation of 301 consecutive renal transplants to define the prevalence and therapy of lymphoceles following renal transplantation. Using a management scheme, we identified in 52 patients (17.3%) perirenal fluid collections. Using this management scheme, we treated 47/52 patients conservatively. Only 5 (1.7%) patients required internal marsupialization. We conclude that groin lympho cysts after renal transplantation can be successfully treated with conservative methods.

The Management of Pelvic Lymphocele

ABSTRACT The occurrence of lymphocele after radical gynecologic surgery is much less common in contemporary practice than was described in early reports on the subject. Nonetheless, it is not an infrequent complication and can be associated with morbidity that may be serious. The case described here illustrates some of the clinical problems that may be encountered, and the discussion focuses on preventive and therapeutic strategies that recently have been appreciated. (J GYNECOL SURG 10:35, 1994)

Complications of low dose heparin prophylaxis following pelvic lymphadenectomy

All patients who underwent pelvic lymphadenectomy for prostatic carcinoma over a five-year period were reviewed to evaluate the effect of minidose heparin prophylaxis on lymphocele formation and postoperative complications. The overall incidence of complications was found to be consistent with that reported in the current literature. However, when the rate of lymphocele occurrence was correlated with perioperative minidose heparin therapy, the incidence rose from 2.5 per cent in those receiving no heparin to 38 per cent in patients receiving both pre- and postoperative prophylactic heparinization. Other major postoperative complications were also significantly increased when minidose heparin was pre- or postoperatively administered. A strong recommendation is made for caution in the routine use of prophylactic low-dose heparin during pelvic surgery.