Key words
symptomatic lymphocele - negative pressure therapy - drainage - interventional procedures
Introduction
Lymphoceles are collections of lymphatic fluid without a distinct epithelial lining.
They typically occur after surgery in areas with an extensive lymphatic network and
are most commonly seen in the retroperitoneum. Procedures such as prostatectomy, perineal
resection for genitourinary malignancy, renal transplantation, vascular bypass procedures,
and breast surgery have a relatively high risk of lymphocele formation [1] with a reported incidence of up to 32 % [2]
[3]
[4]. Lymphoceles mostly occur within weeks up to many months after surgery [5]. Most of them are self-limiting and therefore undiagnosed [6]. Only 4–7 % of lymphoceles become symptomatic [7] with several risk factors that have been reported to be associated with the development
of symptoms such as number of lymph nodes removed, body-mass index, size of lymphoceles,
and age [8]. Symptoms of lymphoceles can be pain, infection, lymphorrhea, and compression of
surrounding structures [4]. When causing deep vein thromboses and pulmonary embolism due to local compression
of pelvic veins, they can cause devastating consequences for patients.
As lymphoceles tend to relapse, treatment may be difficult. Several different techniques
for treatment have been described in the literature [1]
[2]
[9], including simple aspiration, drainage, instillation of sclerosing agents such as
alcohol, povidone iodine and doxycycline, lymphatic embolization, and laparoscopic
or open lymphocele marsupialization. The success rate of these therapies has been
reported to be between 50 % and 98 % (reviewed in [1]
[4]).
In our department the standard technique for dealing with symptomatic lymphoceles
is vacuum-assisted suction drainage, which we believe to have several advantages:
it is an easy, cost-effective, and not painful procedure that can induce cavity collapse
and surface adherence. The reported effects of negative pressure therapy on wound
healing are an increase in local blood flow, stimulation of angiogenesis, formation
of granulation tissue, stimulation of cell proliferation, removing of soluble healing
inhibitors and bacterial load (even pus may be drained completely) [10]. Thus, we believe that vacuum-assisted suction drainage is a good option for the
treatment of symptomatic lymphoceles. Therefore, we conducted this analysis regarding
the success and complication rate and compared our results to the existing literature.
Materials and Methods
All patients over 18 years who underwent vacuum-assisted suction drainage of symptomatic,
postoperative lymphoceles during the years 2008–2020 were included in this study.
During this time period, no other treatment methods for symptomatic lymphoceles (e. g.,
simple drainage without suction) were employed. The local PACS and RIS were interrogated
as a source of data. Data retrieved for each patient included: age, sex, diagnosis,
clinical condition, previous surgery, time span between previous surgery, a diagnosis
of symptomatic lymphocele, CT imaging (including volume of lymphocele), success of
vacuum-assisted suction drainage, number of drainage procedures, complication rate
and indwelling time for the suction drain. Ethical approval for this study was obtained
from the local ethics committee (Ethikkommission der Medizinischen Fakultät der Ruhr-Universität Bochum, Sitz Ostwestfalen;
Approval Number 2021–788).
All drainage catheters were placed under local anesthesia and mild sedation (2–3 mg
Midazolam i. v.) and CT guidance. Before the intervention, coagulation parameters
were checked to make sure that there was no elevated risk for bleeding. In all cases
thrombocytes were > 50 000 µl and INR < 1.5. In cases of superinfection, antibiotics
were administered.
Fully informed consent was obtained in all cases by the radiologist performing the
drainage procedure with an explanation of the principles of the procedure, the resulting
consequences, possible complications, and their potential solutions. For the procedure,
the patient was placed either in a prone or a supine position. After a native CT planning
scan and CT-guided marking of the puncture side on the skin, sterile draping and disinfection
of the skin was performed. A contrast-enhanced CT scan for planning was only performed
when we suspected the presence of dangerous vascular variants or varices, which could
lead to further complications. Local anesthesia of the skin and puncture canal was then
carried out. In the trocar technique, a needle-mounted 8.5 F drain (Resolve locking
catheter, 15 cm, Merit Medical Systems Inc., South Jordan, Utah, USA) or a needle-mounted
8 F drain (Malecot direct puncture basket-drainage set [Malecot Direktpunktions-Körbchen-Set,
hydrophil], Sikamed, Wiehl, Germany), which is very suitable for small lymphoceles,
was advanced into the lymphocele after skin puncture. After verification of the correct
position of the drain in the lymphocele by removing the inner needle and aspiration,
the drain was pushed further into the lymphocele (without needle) and the pigtail
was unrolled and locked. The drainage catheter was then fixed at skin level by suture.
A small amount of cystic fluid was aspirated for cytological and microbiological analysis.
Then, the Redon container (PRIVAC 400 OP-System; vacuum 900 mbar) was prepared according
to [Fig. 1] by cutting off the head of the cone of the tube ([Fig. 1]) and was connected with the drainage catheter. The vacuum locks of the Redon container
were removed, and lymph fluid was aspirated continuously. Sterile dressing of the
drain was carried out afterwards.
Fig. 1 Material preparation for connection of Redon tube and drainage catheter. A After cutting off the tip of the connective tube of Redon, it fits perfectly over
the end of the drainage catheter B. You can see the suture of the locking mechanism (white arrow in B). C Shows Redon container (400 ml).
Abb. 1 Vorbereitung des Materials für die Verbindung von Redon-Schlauch und Drainage A: Nach Zuschneiden des Redon-Universalverbinders passt dieser perfekt über das Drainageende
B. Man kann die Fadensicherung der Drainage (zur Sicherung der Pigtail-Konfiguration)
sehen (weißer Pfeil in B). C Diese Abb. zeigt die Redon-Flasche.
The postprocedural management is recommended as follows: The drainage catheter should
remain in place for at least 4 days with vacuum suction after output had ceased. The
vacuum and the Redon container should be checked twice a day, i. e., this includes
regular changes of the Redon container when full (to ensure continuous suction) and
regular changes of the sterile dressing (at least every two days). Regular flushing
of the drainage catheter with small amounts of sterile saline every day to avoid blocking
of the catheter was recommended as well. This procedure could also be performed on
an outpatient basis. Before removal of the catheter, CT imaging should be performed
to make sure that the lymphocele is no longer visible.
Results
Between 2008 and 2020, 35 patients with symptomatic postoperative lymphoceles were
treated in our department. In total, 39 symptomatic lymphoceles occurred in these
patients. The mean time interval between surgery and onset of symptoms was 71 days
(ranging from 8 days to 572 days). Most patients were male and had previous surgery
due to prostatic carcinoma (for patient characteristics see [Table 1]). 30 patients had a single symptomatic lymphocele. One patient post-prostatectomy
had two bilateral symptomatic lymphoceles that were drained simultaneously (see [Fig. 2]). In two patients, there were two ipsilateral symptomatic lymphoceles in different
locations that were drained. One patient had 3 ipsilateral symptomatic lymphoceles
in different locations that occurred successively and therefore were drained successively.
Table 1
Overview of patient characteristics and number and location within the patients.
Tab. 1 Übersicht der Patientencharakteristiken sowie der Anzahl und Seite innerhalb der
Patienten.
|
number of patients
|
35
|
|
male
|
27
|
|
female
|
8
|
|
mean age
|
65 (range: 36–86)
|
|
previous surgery performed:
|
|
|
|
24
|
|
|
3
|
|
|
7
|
|
|
1
|
|
number of treated symptomatic lymphoceles
|
39
|
|
number and location within the patients:
|
|
|
|
30 (28 pelvic, 1 retroperitoneal, 1 cervical)
|
|
|
1 (pelvic)
|
|
|
2 (pelvic)
|
|
|
1 (pelvic)
|
Fig. 2 Successful drainage catheter placement in a patient 43 days post-prostatectomy with
symptomatic postoperative lymphoceles. A In total, three lymphoceles could be detected on CT scan. The third smaller lymphocele
on the left side cranial to the two in the pelvis was assessed as non-symptomatic
and was therefore not treated. B The CT image shows the result after double-sided drainage catheter placement in the
lymphoceles neighboring the iliac vessels which causes total deflation of lymphocele
cavities and immediate pain relief.
Abb. 2 Erfolgreiche Drainageeinlage in einen Patienten 43 Tage nach Prostatektomie bei symptomatischen
Lymphozelen beidseits. A Insgesamt konnten 3 Lymphozelen in der CT-Untersuchung abgegrenzt werden. Die kleinste
der 3 Lymphozelen außerhalb des kleinen Beckens links wurde als nichtsymptomatisch
eingestuft und daher nicht drainiert. B Diese Abb. zeigt das Ergebnis nach beidseitiger Drainageeinlage in die Lymphozelen
mit direkter Lagebeziehung zu den Iliakalgefäßen. Die Drainageeinlagen resultierten
in einer vollständigen Deflation der Lymphzelen, was zu einer sofortigen Schmerzlinderung
führte.
Patients suffered from several different symptoms of lymphoceles (see [Table 2]). 27 patients had signs of infection. Since some patients had more than one symptomatic
lymphocele, 29 lymphoceles had signs of superinfection. Three patients had additional
deep vein thrombosis, with two developing pulmonary embolisms. Unfortunately, one
patient died after placement of the drainage catheter due to pulmonary embolism (non-procedure-related
death). Therefore, this case was excluded from statistical analysis. This patient
had not only already suffered a severe pulmonary embolism but also a sepsis. Therefore,
the drainage catheter was placed despite pulmonary embolism to remove the infected
lymphocele and thus eliminate the underlying cause of infection.
Table 2
Overview of clinical manifestation of symptomatic lymphoceles. Most patients had signs
of infection. Many patients had additional complaints or manifestations like edema
or deep vein thrombosis.
Tab. 2 Übersicht über die klinische Manifestation der Lymphozelen. Die meisten Patienten
hatten Zeichen der Superinfektion. Viele Patienten hatten darüber hinaus noch weitere
Beschwerden oder Manifestationen wie Ödeme oder Thrombosen.
|
symptoms
|
no. of patients
|
|
infection (fever, sepsis)
|
27
|
|
pain and/or edema
|
6
|
|
leg paresis
|
1
|
|
gastrointestinal dysfunction/disturbed transit due to local compression
|
1
|
|
some patients had additional symptoms:
|
|
|
|
2
|
|
|
2
|
|
|
1
|
Before the procedure, all patients received a CT or MRI scan in order to estimate
the location and volume of the lymphocele according to the approximation formula [11]
[12]: craniocaudal diameter × sagittal diameter × axial diameter × 0.5.
In total, 39 symptomatic lymphoceles were treated with 43 drainage catheters in 35
patients. 4 lymphoceles needed a second drainage because of relapse or dislocation
of the drainage catheter. Diagnosis of lymphocele and superinfection was retrospectively
confirmed on the basis of biochemical and cytologic findings in aspirated fluid.
All but two lymphoceles had a maximum diameter of > 5 cm. For these two very small
lymphoceles, the basket-drainage catheter (Sikamed) was used, for the other larger
lymphoceles the pigtail drainage catheter (Merrit) was used. The mean volume of lymphoceles
was 220 ml (range 9–1393 ml).
The technical success of 8–8.5 F drainage catheter placement was 100 %. Quick improvement
of (local) clinical symptoms of lymphocele could be achieved in all patients. The
mean time interval with the drainage catheter in place was 8.5 days (ranging from
1 to 30 days). One patient died after drainage catheter placement due to a fatal preexisting
pulmonary embolism on the basis of a deep vein thrombosis and sepsis and therefore
was excluded from statistical analysis (non-procedure-related death). 4 lymphoceles
needed a second drainage procedure due to relapse. In all 4 cases the time period
with the drainage catheter in place was only 3 days for unknown reasons, which was
relatively short and against our recommendation. In these cases, the time interval
until the appearance of relapse was between 18 and 30 days.
The success rate of the procedure was 94.8 %, with 37 of 39 lymphoceles being able
to be cured completely with disappearance of lymphocele (see [Fig. 3]). In two patients (one with a cervical lymphocele after lymph node excision (see
[Fig. 4]) and one with sepsis after prostatectomy), interdisciplinary discussion decided
to perform surgery after 10 days of vacuum-assisted suction drainage with no tendency
toward suspended output.
Fig. 3 Successful drainage catheter placement in a female patient with symptomatic lymphocele
22 days after extended tumor surgery due to ovarian carcinoma. A paraaortal lymph
node excision was performed as well. The patient suffered from disturbed gastric and
duodenal transit because of a retroperitoneal lymphocele compressing the distal duodenum
(white arrow in A and B). Drainage catheter placement was carried out with the patient in prone position
using the trocar technique. C shows the result after drainage catheter placement with total deflation of the lymphocele
cavity and relief of symptoms.
Abb. 3 Erfolgreiche Drainageeinlage in eine Patientin mit symptomatischer Lymphozele 22
Tage nach ausgedehnter Tumoroperation aufgrund eines Ovarialkarzinoms. Eine Exzision
der paraaortalen Lymphknoten wurde ebenfalls durchgeführt. Die Patientin litt an einer
gestörten duodenalen und gastrischen Passage aufgrund der Kompression des Duodenums
durch eine symptomatische Lymphozele (weißer Pfeil in A und B). Die Drainageeinlage in Tokar-Technik wurde mit der Patientin in Bauchlagerung durchgeführt.
C Diese Abb. zeigt das Resultat der Drainageeinlage mit einer totalen Deflation der
Lymphozele. Die Patientin war danach beschwerdefrei.
Fig. 4 Drainage catheter placement in a symptomatic cervical lymphocele post-lymph node
excision with the patient suffering from fever and pain failed to cure the lymphocele
completely. Even after 10 days of catheter drainage (white arrow), the lymphocele
was still visible. The positive effect of the drainage procedure was symptom relief.
Abb. 4 Drainageeinlage in eine symptomatische zervikale Lymphozele nach Lymphknotenexzision:
Der Patient litt an Fieber und Schmerzen. Die Drainage (weißer Pfeil) konnte die Lymphozele
in diesem Fall leider nicht zur Ausheilung bringen. Sogar nach 10 Tagen mit einliegender
Drainage war die Lymphozele noch abzugrenzen. Der positive Effekt der Drainage war
jedoch die Beschwerdelinderung.
The complication rate was 4.6 % (2/43). Both complications were minor complications
[13] and according to the CIRSE Classification system Grade 2 and Grade 3, respectively
[14]. One patient had a small hematoma in the drainage canal and one showed signs of
infection of the drainage canal several weeks after removal of the drainage catheter.
Discussion
Many methods for the treatment of symptomatic lymphoceles have been described. None
of these methods is explicitly recommended as the standard of care, as there are no
distinctive guidelines.
With a success rate of 94.8 %, our results using vacuum drainage are in the upper
range of reported success rates for different treatment options for lymphoceles: Instillation
of povidone iodine has a reported success rate of 90 % [15], and the success rate of sclerotherapy has been described to range from 77 % to
94 % with a higher catheterization duration (up to 60 days) [1]
[16]
[17] compared to our method. In the past, surgery was the treatment of choice with reported
success rates of 80–90 % for internal marsupialization [18]
[19]. Lymphangiography and lymphatic embolization have been proposed as a second-line
treatment after failed percutaneous drainage with a success rate of 100 % [20] in a small patient cohort.
Existing literature has reported that most symptomatic lymphoceles have a diameter
exceeding 5 cm [8]. In our patient collective, all but two symptomatic lymphoceles were quite large
with at least one diameter exceeding 5 cm. In the case of quite large lymphoceles,
drainage catheter placement was easy, and the technical success rate was 100 %. Dislocation
of the drainage catheter was a problem in the beginning after implementation of the
protocol. However, after materials were replaced with locked drainage catheters with
suture-fixed pigtails, dislocation was less frequent.
A simple drainage catheter can be inserted into symptomatic lymphoceles as a valuable
therapy, but it has been reported that 23–50 % of lymphoceles re-expand after removal
of the catheter [21]. As suction drainage can prevent the formation of lymphoceles or can treat lymphatic
leakages [22]
[23]
[24]
[25]
[26]
[27] and suction drainage of wounds after surgery is a long-established surgical practice
since the introduction of suction drainage in the 1950s [28], we think that suction drainage of existing symptomatic lymphoceles is also a valuable
and a successful method. We think that the effects of suction drainage of lymphoceles
are as follows: (1) suction drainage can induce cavity collapse and (2) surface adherence,
(3) and even pus may be drained completely [30]. Indeed, we observed that due to the suction, even purulent lymphoceles could be
immediately and totally drained after drainage insertion. Additionally, there are
investigations in the literature dealing with different sizes of drainage catheters.
In that study [29], no relevant difference between large and small drainage catheters concerning drainage
outcome was observed, even in particularly viscous – and thus complicated – necrotizing
pancreatitis. Therefore, it was not necessary to use larger catheter sizes. The 8
F and 8.5 F drainage catheters worked fine for our treatment of lymphoceles. As stated
above, our protocol included regular checks of the catheter and flushing with small
amounts of sterile saline to avoid obstruction of the drainage catheter. Positive
effects of negative-pressure therapy in local wound therapy have been investigated
since the 1980s (reviewed in [10]). The following effects have been described: increase in blood flow, promotion of
angiogenesis, and induction of cell proliferation. We believe that due to these effects
and due to continuous suction/aspiration of lymph fluid, surface adherence and also
healing is induced as long as continuous suction is present. To find a suture-locked
catheter with pigtail configuration and a Redon container in combination that could
maintain the vacuum after connecting the catheter with the container needed a bit
of research and testing of different combinations. A premounted drainage catheter
with a suture locking mechanism with a pigtail configuration (Merrit Resolve locking
catheter) or basket configuration (basket drainage catheter, Sikamed) was ultimately
suitable to maintain the vacuum after connection with the Redon container. We determined
that our “preparation” of the container tube was the best method to connect both.
As another positive effect of our protocol, we could not find any catheter dislodgement.
In our patient collective the suture-locked pigtail configuration seems to be able
to effectively prevent catheter dislodgement. Our protocol has some other positive
effects: It is an easy and minimally invasive procedure in a closed system with rapid
clinical improvement in all patients. Regarding relapse, our protocol was able to
prevent re-expansion in all but 4 lymphoceles (relapse rate: 11 %), which is much
better than previously published results [16]
[17]. Our therapy with suction drainage failed in two patients (one with a cervical lymphocele
after lymph node excision and one with sepsis after prostatectomy). A connection between
this failure and the underlying condition of the patients could not be observed, and
due to the low number of cases (n = 2), statistical evaluation was not possible. To
investigate if the underlying entity has an influence of the rate of failure, further
investigation with larger case numbers is necessary.
Compared to surgical procedures like marsupialization [31], the minimally invasive method of image-guided drainage has the advantage of a relatively
small access way, which corresponds to the thickness of the drainage catheter. As
a result, the interventionalist has more freedom when choosing the access trajectory
of the drainage catheter. Aspects like postoperative and/or age-related anatomical
alterations (e. g., vessel kinking or varices) as well as patient comfort (especially
given the relatively long duration of the indwelling drainage catheter) can be taken
into account when planning the access way for the drainage catheter. However, due
to the greater freedom compared to a surgical procedure and the other restrictions
mentioned above, access planning in this minimally invasive approach is harder to
standardize or formalize. Therefore, it requires more experience on the part of the
interventionalist in planning the access trajectory. The disadvantage of our protocol
is the relatively long time period of suction to ensure surface adherence. The drainage
catheter should remain for at least 4 days with vacuum suction after output had stopped.
This time period of treatment with a drainage catheter present is comparable with
some other therapy options. For lymphangiography and lymphatic embolization, the median
time to resolution was 7 days [20]. For sclerotherapy there are also quite long mean catheterization times of 11.8
days (1–60 days; [17]). We had a median time of indwelling catheter of 8.5 days until resolution. As the
procedure is not painful, most patients did not complain.
Clinical relevance of this study: Our protocol of suction drainage is an easy and
successful method to cure symptomatic lymphoceles at various locations with rapid
clinical improvement and a low tendency of relapse.
