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Rofo 2020; 192(11): 1025-1035
DOI: 10.1055/a-1131-7889
Review

Conventional Lymphangiography (CL) in the Management of Postoperative Lymphatic Leakage (PLL): A Systematic Review

Konventionelle Lymphangiografie (KL) beim Management postoperativer Lymphleckagen (PLL): Eine Systematische Übersicht
Christof M. Sommer
1   Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Germany
,
Claus C. Pieper
2   Department of Radiology, University Hospital Bonn, Germany
,
Maxim Itkin
3   Center for Lymphatic Imaging and Interventions, Hospital of the University of Philadelphia, Germany
,
Gregory J. Nadolski
3   Center for Lymphatic Imaging and Interventions, Hospital of the University of Philadelphia, Germany
,
Saebeom Hur
4   Department of Radiology, Seoul National University Hospital, Seoul, Korea (the Republic of)
,
Jinoo Kim
5   Department of Radiology, Ajou University Hospital, Suwon, Korea (the Republic of)
,
Geert Maleux
6   Department of Radiology, University Hospitals Leuven, Belgium
,
Hans-Ulrich Kauczor
1   Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Germany
,
Goetz M. Richter
7   Clinic for Diagnostic and Interventional Radiology, Klinikum Stuttgart, Germany
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Abstract

Background Postoperative lymphatic leakage (PLL) is usually managed by conservative and/or surgical treatments but these procedures can be challenging to perform and potentially clinically ineffective. Therefore, conventional lymphangiography (CL) has emerged as an important alternative. The aim of this review is to present the available outcome data on CL in the management of PLL.

Method A systematic literature search (PubMed) using the MeSH term “lymphangiography” was performed and the search was restricted to literature published between January 2007 and August 2019. Identification, screening, and assessment for eligibility and inclusion were conducted in accordance with PRISMA.

Results From the initially obtained 1006 articles (identification), 28 articles with a total of 201 patients were finally included (inclusion). The methodological quality of all included articles corresponds to level 4 (Oxford Centre for Evidence-based Medicine – Levels of Evidence, March 2009). PLL occurs after oncological and non-oncological surgery in the form of chylothorax, chylous ascites, and cervical, thoracic, abdominal and peripheral lymph fistula and/or lymphocele. The technical success rate of CL is 75–100 %. Access for CL is transpedal (176 patients) or intranodal (25 patients). Lipiodol is used as the contrast material in all articles, with a maximum amount of 20 ml for transpedal CL and 30 ml for intranodal CL. The X-ray imaging modalities used for CL are fluoroscopy, radiography and/or CT. Two articles report CL-associated major complications and CL-associated morbidity and mortality. The PLL cure rate is 51–70 % for transpedal CL (time to PLL cure: 2–29 days) and 33–100 % for intranodal CL (time to PLL cure: 2–< 30 days). Bailout procedures in the case of clinically ineffective CL include a range of treatments.

Conclusion CL is feasible, safe, and effective in the management of PLL. Lipiodol as the contrast material is essential in CL because the highly viscous iodinated poppy-seed oil has not only diagnostic but therapeutic effects. Guidelines and randomized controlled trials are further steps towards defining the ultimate value of CL.

Key Points: 

  • PLL is a difficult-to-treat and potentially life-threatening surgical complication.

  • CL has emerged as an alternative to conservative/surgical treatment of PLL.

  • CL is feasible, safe, and effective in the management of PLL

  • Lipiodol-based CL can be regarded as a therapeutic procedure.

  • Guidelines and randomized controlled trials are further important steps.

Citation Format

  • Sommer CM, Pieper CC, Itkin M et al. Conventional Lymphangiography (CL) in the Management of Postoperative Lymphatic Leakage (PLL): A Systematic Review. Fortschr Röntgenstr 2020; 192: 1025 – 1035

Zusamenfassung

Hintergrund Die postoperative Lymphleckage (PLL) wird meist konservativ und/oder chirurgisch behandelt, jedoch können diese Behandlungen anspruchsvoll und potenziell klinisch ineffektiv sein. Die konventionelle Lymphangiografie (KL) entwickelte sich zur wichtigen Alternative. Ziel der vorliegenden Übersicht ist es, die verfügbaren Outcome-Daten zur KL beim Management der PLL darzustellen.

Methode Eine systematische Literaturrecherche (PubMed) unter Verwendung des MeSH-Begriffs „lymphangiography” wurde durchgeführt, wobei ausschließlich Artikel berücksichtigt wurden, die zwischen Januar 2007 und August 2019 publiziert wurden. Identifikation, Screening sowie Beurteilung auf Eignung und Einschluss erfolgten in Übereinstimmung mit PRISMA.

Ergebnisse Von den ursprünglich erhaltenen 1006 Artikeln (Identifikation) wurden letztendlich 28 Artikel mit insgesamt 201 Patienten eingeschlossen (Einschluss). Die methodische Qualität aller eingeschlossenen Artikel entspricht Level 4 (Oxford Centre for Evidence-based Medicine – Levels of Evidence, March 2009). Die PLL tritt nach onkologischen und nichtonkologischen Operationen in Form von Chylothorax, chylösem Aszites sowie zervikalen, thorakalen, abdominellen, pelvinen und peripheren Lymphfisteln und/oder Lymphozelen auf. Die technische Erfolgsrate der CL liegt bei 75–100 %. Der Zugang für die CL ist transpedal (176 Patienten) oder intranodal (25 Patienten). Lipiodol wird in allen Artikeln als Kontrastmittel verwendet, mit einer Maximaldosis von 20 ml für die transpedale CL und 30 ml für die intranodale CL. Röntgen-Bildgebungsmodalitäten beinhalten Fluoroskopie, Radiografie und/oder CT. 2 Artikel berichten über CL-assoziierte Major-Komplikationen sowie CL-assoziierte Morbidität und Mortalität. Die PLL-Abheilungsrate beträgt 51–70 % für die transpedale CL (Abheilungszeit: 2–29 Tage) bzw. 33–100 % für die intranodale CL (Abheilungszeit: 2–< 30 Tage). Rettungsprozeduren im Fall der klinisch ineffektiven CL beinhalten unterschiedliche Behandlungen.

Schlussfolgerung Die KL ist technisch machbar und sicher und effektiv beim Management der PLL. Lipiodol als Kontrastmittel spielt für die KL eine essenzielle Rolle, da das hochvisköse jodierte Mohnöl nicht nur diagnostische, sondern auch therapeutische Effekte aufweist. Leitlinien und randomisierte kontrollierte Studien sind weitere Schritte, um den tatsächlichen Nutzen der KL zu definieren.

Kernaussagen: 

  • Die PLL ist eine schwer behandelbare und potenziell lebensbedrohliche chirurgische Komplikation.

  • Die KL entwickelte sich als Alterative zur konservativen/operativen Behandlung der PLL.

  • Die KL ist technisch machbar und sicher und effektiv beim Management der PLL.

  • Die Lipiodol-basierte KL kann als therapeutische Prozedur angesehen werden.

  • Leitlinien und randomisierte kontrollierte Studien sind weitere wichtige Schritte.

Key words

lymphangiography - conventional - postoperative lymphatic leakage - lymph fistula - Lipiodol


Publication History

Received: 02 January 2020

Accepted: 13 February 2020

Article published online:
26 March 2020

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

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