Rofo 2022; 194(06): 634-643
DOI: 10.1055/a-1717-2467
Interventional Radiology

Treatment of Postoperative Lymphatic Leakage Applying Transpedal Lymphangiography – Experience in 355 Consecutive Patients

Behandlung von postoperativen Lymphleckagen mittels transpedaler Lymphangiografie – Erfahrungsbericht bei 355 aufeinanderfolgenden Patienten
1   Clinic of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Germany
2   Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
,
Goetz M Richter
3   Clinic for Diagnostic and Interventional Radiology, Klinikum Stuttgart Katharinenhospital, Stuttgart, Germany
,
1   Clinic of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Germany
,
Hans-Ulrich Kauczor
1   Clinic of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Germany
,
Rosa Klotz
4   Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Germany
,
Thilo Hackert
4   Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Germany
,
Martin Loos
4   Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Germany
,
1   Clinic of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Germany
3   Clinic for Diagnostic and Interventional Radiology, Klinikum Stuttgart Katharinenhospital, Stuttgart, Germany
5   Department of Nuclear Medicine, University Hospital Heidelberg, Germany
6   Clinic of Radiology and Neuroradiology, Sana Clinics Duisburg, Germany
› Institutsangaben

Abstract

Purpose Report of experience from a single institution in treating postoperative lymphatic leakage (PLL) applying conventional transpedal lymphangiography (TL).

Materials and Methods 453 patients with the initial diagnosis of PLL receiving TL between 03/1993 and 09/2018 were identified in the database. Only patients with confirmed PLL were included in the study. The technical success, safety, and treatment success of TL were evaluated. Independent predictors of TL treatment failure were examined using univariate and multivariate logistic regression analysis.

Results 355 consecutive patients (218 men, 137 women; median age of 62 years) who underwent TL for PLL (e. g., chylothorax) after ineffective conservative treatment were included. The median time between causal surgery and TL was 27 days. The median technical success rate of TL was 88.5 %, with a median volume of Lipiodol of 10.0 ml. No complication of TL was recorded. Three groups were defined according to the different clinical courses: group A (41/355, 11.5 %) – TL with technical failure; group B (258/355, 72.7 %) – “therapeutic” TL alone with technical success; and group C (56/355, 15.8 %) – “diagnostic” TL with simultaneously invasive treatment (incl. surgical revision and percutaneous sclerotherapy). Treatment success rate and median time to treatment success were higher in group C than in group B, but without significant differences (64.3 % vs. 61.6 %, p = 0.710; six vs. five days, p = 0.065). Univariate and multivariate logistic regression analyses for group B confirmed drainage volume (> 500 ml/d) and Lipiodol extravasation as independent predictors of TL clinical failure (odds ratios [ORs] of 2.128 and 2.372 [p = 0.005 and p = 0.003, respectively]).

Conclusion TL is technically reliable, safe, and effective in treating PLL. When conservative treatment fails, TL can be regarded as the next treatment option.

Key Points:

  • TL is technically reliable, safe, and effective for treating PLL.

  • When conservative treatment fails, TL can be regarded as the next treatment option.

  • Drainage volume > 500 ml/day is an independent predictor of clinical failure after TL.

  • Lipiodol extravasation is an independent predictor of clinical failure after TL.

Citation Format

  • Pan F, Richter GM, Do TD et al. Treatment of Postoperative Lymphatic Leakage Applying Transpedal Lymphangiography – Experience in 355 Consecutive Patients. Fortschr Röntgenstr 2022; 194: 634 – 643

Zusammenfassung

Ziel Erfahrungsbericht über die interventionelle Behandlung der postoperativen Lymphleckage (PLL) mittels konventioneller transpedaler Lymphangiografie (TL).

Material und Methoden Über digitale Datenbanken konnten 453 Patienten identifiziert werden, die in unserer Klinik zwischen 03/1993 und 09/2018 eine TL erhielten. Von diesen Patienten wurden lediglich diejenigen eingeschlossen, die eine TL aufgrund einer PLL erhielten. Der technische Erfolg, die Sicherheit und das klinische Ergebnis der TL wurden bewertet. Unabhängige Prädiktoren für das klinische Versagen nach TL wurden mittels univariater und multivariater logistischer Regressionsanalyse identifiziert.

Results Bei 355 konsekutiven Patienten (218 Männer, 137 Frauen; medianes Alter 62 Jahre) wurde eine TL bei klinischem Versagen nach konservativer Behandlung einer PLL (z. B. Chylothorax) durchgeführt. Das mediane Zeitintervall zwischen kausaler Operation und TL betrug 27 Tage. Die mediane technische Erfolgsrate von TL betrug 88,5 % bei einem medianen Lipiodol-Volumen von 10,0 ml. Es wurde keine Komplikation der TL beobachtet. Entsprechend den verschiedenen klinischen Verläufen wurden 3 Patientengruppen definiert: Gruppe A (41/355, 11,5 %) – TL mit technischem Versagen; Gruppe B (258/355, 72,7 %) – „therapeutische“ TL allein mit technischem Erfolg; und Gruppe C (56/355, 15,8 %) – „diagnostische“ TL mit gleichzeitig invasiver Behandlung (inkl. chirurgische Revision und perkutane Sklerotherapie). Die mediane klinische Erfolgsrate und das mediane Zeitintervall bis zum klinischen Erfolg nach TL waren in Gruppe C höher als in Gruppe B, jedoch ergaben sich hierbei keine signifikanten Unterschiede (64,3 % vs. 61,6 %, p = 0,710; 6 vs. 5 Tage, p = 0,065). Univariate und multivariate logistische Regressionsanalysen für Gruppe B identifizierten das Drainagevolumen (> 500 ml/Tag) und die Extravasation von Lipiodol als unabhängige Prädiktoren für das klinische Versagen nach TL (Odds Ratios [ORs] von 2,128 und 2,372 [p = 0,005 bzw. p = 0,003]).

Schlussfolgerung Die TL ist technisch zuverlässig, sicher und wirksam bei der Behandlung der PLL. Wenn die konservative Behandlung versagt, kann die TL als nächste Behandlungsoption angesehen werden.

Kernaussagen:

  • Die TL ist technisch zuverlässig, sicher und wirksam bei der Behandlung der PLL.

  • Wenn die konservative Behandlung versagt, kann die TL als nächste Behandlungsoption angesehen werden.

  • Ein Drainagevolumen von > 500 ml/Tag ist ein unabhängiger Prädiktor für klinisches Versagen nach TL.

  • Die Extravasation von Lipiodol ist ein unabhängiger Prädiktor für das klinische Versagen nach TL.



Publikationsverlauf

Eingereicht: 31. Mai 2021

Angenommen: 18. November 2021

Artikel online veröffentlicht:
26. Januar 2022

© 2022. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 
  • References

  • 1 Sommer CM, Pieper CC, Itkin M. et al. Conventional Lymphangiography (CL) in the Management of Postoperative Lymphatic Leakage (PLL): A Systematic Review. Rofo 2020; 192: 1025-1035
  • 2 Sriram K, Meguid RA, Meguid MM. Nutritional support in adults with chyle leaks. Nutrition 2016; 32: 281-286
  • 3 Lv S, Wang Q, Zhao W. et al. A review of the postoperative lymphatic leakage. Oncotarget 2017; 8: 69062-69075
  • 4 Itkin M, Kucharczuk JC, Kwak A. et al Nonoperative thoracic duct embolization for traumatic thoracic duct leak: experience in 109 patients. J Thorac Cardiovasc Surg 2010; 139: 584-589 ; discussion 589–590
  • 5 Nadolski GJ, Chauhan NR, Itkin M. Lymphangiography and Lymphatic Embolization for the Treatment of Refractory Chylous Ascites. Cardiovasc Intervent Radiol 2018; 41: 415-423
  • 6 Cope C, Kaiser LR. Management of unremitting chylothorax by percutaneous embolization and blockage of retroperitoneal lymphatic vessels in 42 patients. J Vasc Interv Radiol 2002; 13: 1139-1148
  • 7 Baek Y, Won JH, Kong TW. et al. Lymphatic Leak Occurring After Surgical Lymph Node Dissection: A Preliminary Study Assessing the Feasibility and Outcome of Lymphatic Embolization. Cardiovasc Intervent Radiol 2016; 39: 1728-1735
  • 8 Meyer CD, McLeod IK, Gallagher DJ. Conservative Management of an Intraoperative Chyle Leak: A Case Report and Literature Review. Mil Med 2016; 181: e1180-e1184
  • 9 Kumar S, Kumar A, Pawar DK. Thoracoscopic management of thoracic duct injury: Is there a place for conservatism?. J Postgrad Med 2004; 50: 57-59
  • 10 Kim BS, Kwon TG. Chylous ascites in laparoscopic renal surgery: Where do we stand?. World Journal of Clinical Urology 2016; 5: 37
  • 11 Delaney SW, Shi H, Shokrani A. et al. Management of Chyle Leak after Head and Neck Surgery: Review of Current Treatment Strategies. Int J Otolaryngol 2017; 2017: 8362874
  • 12 Schild HH, Strassburg CP, Welz A. et al. Treatment options in patients with chylothorax. Dtsch Arztebl Int 2013; 110: 819-826
  • 13 Pieper CC, Hur S, Sommer CM. et al. Back to the Future: Lipiodol in Lymphography-From Diagnostics to Theranostics. Invest Radiol 2019; 54: 600-615
  • 14 Pan F, Loos M, Do TD. et al. The roles of iodized oil-based lymphangiography and post-lymphangiographic computed tomography for specific lymphatic intervention planning in patients with postoperative lymphatic fistula: a literature review and case series. CVIR Endovasc 2020; 3: 79
  • 15 Sommer CM, Pieper CC, Offensperger F. et al. Radiological management of postoperative lymphorrhea. Langenbecks Arch Surg 2021; 406: 945-969
  • 16 Xu KF, Hu XW, Tian XL. et al. Clinical analysis of 123 cases of chylous effusion. Zhonghua Yi Xue Za Zhi 2011; 91: 464-468
  • 17 Liu DY, Shao Y, Shi JX. Unilateral pedal lymphangiography with non-contrast computerized tomography is valuable in the location and treatment decision of idiopathic chylothorax. J Cardiothorac Surg 2014; 9: 8
  • 18 Pan F, Loos M, Do TD. et al. Percutaneous afferent lymphatic vessel sclerotherapy for postoperative lymphatic leakage after previous ineffective therapeutic transpedal lymphangiography. Eur Radiol Exp 2020; 4: 60
  • 19 Kortes N, Radeleff B, Sommer CM. et al. Therapeutic lymphangiography and CT-guided sclerotherapy for the treatment of refractory lymphatic leakage. J Vasc Interv Radiol 2014; 25: 127-132
  • 20 Hill H, Srinivasa RN, Gemmete JJ. et al. Endolymphatic Ethiodized Oil Intranodal Lymphangiography and Cyanoacrylate Glue Embolization for the Treatment of Postoperative Lymphatic Leak After Robot-Assisted Laparoscopic Pelvic Resection. J Endourol Case Rep 2018; 4: 66-71
  • 21 Majdalany BS, Saad WA, Chick JFB. et al. Pediatric lymphangiography, thoracic duct embolization and thoracic duct disruption: a single-institution experience in 11 children with chylothorax. Pediatr Radiol 2018; 48: 235-240
  • 22 Majdalany BS, Khayat M, Downing T. et al. Lymphatic interventions for isolated, iatrogenic chylous ascites: A multi-institution experience. Eur J Radiol 2018; 109: 41-47
  • 23 Kos S, Haueisen H, Lachmund U. et al. Lymphangiography: forgotten tool or rising star in the diagnosis and therapy of postoperative lymphatic vessel leakage. Cardiovasc Intervent Radiol 2007; 30: 968-973
  • 24 Kawasaki R, Sugimoto K, Fujii M. et al. Therapeutic effectiveness of diagnostic lymphangiography for refractory postoperative chylothorax and chylous ascites: correlation with radiologic findings and preceding medical treatment. Am J Roentgenol 2013; 201: 659-666
  • 25 Boffa DJ, Sands MJ, Rice TW. et al. A critical evaluation of a percutaneous diagnostic and treatment strategy for chylothorax after thoracic surgery. Eur J Cardiothorac Surg 2008; 33: 435-439
  • 26 Khalilzadeh O, Baerlocher MO, Shyn PB. et al. Proposal of a New Adverse Event Classification by the Society of Interventional Radiology Standards of Practice Committee. J Vasc Interv Radiol 2017; 28: 1432-1437 e1433
  • 27 Yoshimatsu R, Yamagami T, Miura H. et al. Prediction of therapeutic effectiveness according to CT findings after therapeutic lymphangiography for lymphatic leakage. Jpn J Radiol 2013; 31: 797-802
  • 28 Gruber-Rouh T, Naguib NNN, Lehnert T. et al. Direct lymphangiography as treatment option of lymphatic leakage: indications, outcomes and role in patient's management. Eur J Radiol 2014; 83: 2167-2171
  • 29 Kim SW, Hur S, Kim SY. et al. The Efficacy of Lymph Node Embolization Using N-Butyl Cyanoacrylate Compared to Ethanol Sclerotherapy in the Management of Symptomatic Lymphorrhea after Pelvic Surgery. J Vasc Interv Radiol 2019; 30: 195-202 e191
  • 30 Sheybani A, Gaba RC, Minocha J. Cerebral Embolization of Ethiodized Oil following Intranodal Lymphangiography. Semin Intervent Radiol 2015; 32: 10-13
  • 31 Geeroms B, Demaerel P, Wauters J. et al. Devastating cerebral Lipiodol(R) embolization related to therapeutic lymphangiography for refractory chylothorax in a patient with Behcet's disease. Vasa 2018; 47: 427-430
  • 32 Nadolski GJ, Itkin M. Feasibility of ultrasound-guided intranodal lymphangiogram for thoracic duct embolization. J Vasc Interv Radiol 2012; 23: 613-616
  • 33 Williams AM, Seay TM, Hundley JC. et al. Direct intranodal lymphangiography for recurrent chylous ascites following liver-kidney transplantation. Liver Transpl 2014; 20: 1275-1276
  • 34 Kariya S, Nakatani M, Yoshida R. et al. Repeated Intranodal Lymphangiography for the Treatment of Lymphatic Leakage. Lymphology 2015; 48: 59-63
  • 35 Parvinian A, Mohan GC, Gaba RC. et al. Ultrasound-guided intranodal lymphangiography followed by thoracic duct embolization for treatment of postoperative bilateral chylothorax. Head Neck 2014; 36: E21-E24
  • 36 Kozlov A, Itkin M, Dori Y. et al. Comparison of pedal and intranodal lymphangiography for thoracic duct embolization (TDE) of traumatic chylous leaks. Journal of Vascular and Interventional Radiology 2017; 28: S135
  • 37 Kariya S, Komemushi A, Nakatani M. et al. Intranodal lymphangiogram: technical aspects and findings. Cardiovasc Intervent Radiol 2014; 37: 1606-1610
  • 38 Iwai T, Uchida J, Matsuoka Y. et al. Experience of Lymphangiography as a Therapeutic Tool for Lymphatic Leakage After Kidney Transplantation. Transplant Proc 2018; 50: 2526-2530
  • 39 Smolock AR, Nadolski G, Itkin M. Intranodal Glue Embolization for the Management of Postsurgical Groin Lymphocele and Lymphorrhea. J Vasc Interv Radiol 2018; 29: 1462-1465
  • 40 Srinivasa RN, Chick JFB, Patel N. et al. Transinguinal interstitial (intranodal) lymphatic embolization to treat high-output postoperative lymphocele. J Vasc Surg Venous Lymphat Disord 2018; 6: 373-375
  • 41 Nadolski GJ, Itkin M. Lymphangiography and thoracic duct embolization following unsuccessful thoracic duct ligation: Imaging findings and outcomes. J Thorac Cardiovasc Surg 2018; 156: 838-843
  • 42 Chu HH, Shin JH, Kim JW. et al. Lymphangiography and Lymphatic Embolization for the Management of Pelvic Lymphocele After Radical Prostatectomy in Prostatic Cancer. Cardiovasc Intervent Radiol 2019; 42: 873-879
  • 43 Yannes M, Shin D, McCluskey K. et al. Comparative Analysis of Intranodal Lymphangiography with Percutaneous Intervention for Postsurgical Chylous Effusions. J Vasc Interv Radiol 2017; 28: 704-711
  • 44 Alejandre-Lafont E, Krompiec C, Rau WS. et al. Effectiveness of therapeutic lymphography on lymphatic leakage. Acta Radiol 2011; 52: 305-311