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UDC 616.137.8-089 : 616.423-089.168.1-06
LYMPHATIC COMPLICATIONS OF INGUINAL ACCESS IN RECONSTRUCTIVE OPERATIONS ON ARTERIES
1 Altai State Medical University, Barnaul
2 Multiprofile hospital of JSC Russian Railways at the Barnaul station Ya.N. Shoikhet1, N. G. Khorev12, A.V. Beller2, V.O. Kon'kova1
For the period of2004-2014 reconstructive surgery on the arteries of the lower extremities with the use of inguinal access was performed in 761 patients. Postoperative lymphatic complications (lymphorrhoea), increasing the duration of the hospital period, were noted in 31 (4.1%) patients. Most often, lymphorrhea was observed after isolated inguinal access (5.5%) and access to the femoral vessels in patients who underwent aorto-ileum-femoral reconstruction (5.6%). Less common complications were registered in patients with infrainguinal reconstruction (1.2%). Infection of conduit or operated artery were not registered in these patients. Elimination of lymphatic drainage was performed by surgical (vessel ligation) and conservative (drainage, iodine administration, antibiotics, physiotherapy) methods. There was determined a statistically significant decrease in the duration of the hospital treatment of lymphorrhea with a conservative approach was established. Key words: lymphatic, lymphatic fistula, inguinal access.
Introduction
The injure of lymph sinuses by the implementation of inguinal access to femoral vessels leads to the development of lymphatic complications after reconstructive arterial surgery. Among these complications are differentiated: lymphatic edema [1], lymphoma (lymphocele) [2] and lymphorrhea (lymphatic fistula) [3]. The most common complication is lymphorrhea. In was mentioned for the first time quite recently. In 1978 the British Medical Journal published a letter describing to cases of lymphorrhea of the inguinal region after reconstructive operations on arteries [4]. This publication initiated the necessity of the study of the postsurgical lymphorrhea after reconstructive surgeries with inguinal access. In a year there appeared an article presenting the experience of conservative and surgical approach in the liquidation of lymphatic complications in 12 patients [5]. Recently there has been published a systematic review including qualitative analysis and assimilated results of 46 researches on various methods of lymphatic fistula treatment [3].
Lymphatic complications, including postsurgical lymphorrhea, as a rule, is not life threatening. The development of infection in the reconstruction zone is not registered [5]. Lymphorrhea prolongs the time of hospital treatment. There exist various views on conservative and surgical approaches to the elimination of these complications [6,7]. The objective of our research was to determine the frequency of postsurgical lymphorrhea development by inguinal access to femoral vessels and comparison of various tactics in treatment aimed at the liquidation of this complication.
Materials and methods
During the period of 2004-2014 inguinal access was implemented in 761 patients of the department of vascular surgery of the hospital of Russian
Railways at the Barnaul station, clinical base of the department of departmental surgery named after Professor I.I. Neimark and hospital surgery with the course of further vocational education of ASMU. These patients underwent various reconstructive operations on the arteries of aorto-femoral and femoropopliteal tibial sections of the arterial bed. In clinical practice accepted is the typical variant of this access to vessels, which consists in lateral incision of the tissues from the projection of femoral artery. By the access lymphatic nodes and vessels were moved medially. By the injure of node or lymphatic vessel there was applied a ligature and was made coagulation. In the end of the surgery through a separate puncture made downward and outside the incision the wound was drained by a plastic tube. After that the wound was sutured beginning from the broad fascia of thigh, then the subcutaneous tissue and skin were stitched in layers. This was the standard method for all clinical surgeons.
The research did not include patients in whom the inguinal access was used for the operations on femoral veins (thrombectomy, valvuloplasty, etc.)
The operated patients were divided into three groups depending on the type of surgery (Table 1).
Lymphorrhea from the wound in the inguinal region was registered in 31 patient (4,1%). This number did not include patients with postsurgical seroma, where the accumulation of fluid was not connected with a lymphatic vessel, and patients with infectious complications. Till the moment of lymphorrhea development in the area of postsurgical suture on the 3rd-7th day there was formed lymphoma. Further it opened itself or required opening of the suture. In these patients preserved long-term lymphatic leakage, which requires a significant prolongation of the hospital period. For the elimination of complication there were implied surgical and conservative
Table 1
Characteristics of the groups of operated patients.
Group Number of patients Abs. (%) Operation type Inguinal access characteristics
1 398 (52,3) Thrombectomy, embolectomy, profundoplasty, EAE from CFA, loop EAE of iliac arteries Isolated
2 107 (14,1) Aorto-femoral, iliofemoral shunting, prosthetics Combination of inguinal access with access to iliac arteries and aorta
3 256 (33,6) Femoropopliteal tibial shunting, loop EAE from SFA Combination of inguinal access with access to distal SFA and PA and tibial arteries
Total 761 (100,0)
Note. EAE - endarterectomy, CFA - common femoral artery, SFA - superficial femoral artery, PA - popliteal artery.
approaches. Surgical treatment consisted in the opening of wound edges with electrocoagulation and bandaging of the problematic tissue parts. Conservative measures included elevation of the limb, imposition of a pressure bandage, drainage of the lymphatic fistula, injection of iodine, prescription of anti-infective drugs and
physiotherapy.
The results of the research are presented in absolute and relative numbers, medians (Me). The difference in frequency of symptom occurrence
in the groups was evaluated by chi-square. The qualitative parameters inside the group were evaluated by Cochran's test. The differences were considered statistically significant by p<0,05.
Results
The frequency of complication occurrence varied in various groups of operated patients and depended on the characteristics of inguinal access (Table 2). Lymphorrhea was most frequently registered after the isolated inguinal access (5,5%)
Table 2
Frequency of lymphorrhea in groups of operated patients.
№ Group Number of patients Lymphorrhea Abs. (%) P12 P13 p 1 2-3
1. 1 - isolated inguinal access 398 22 (5,5)
2. 2 - combination of inguinal access with the access to access to aorta and iliac arteries 107 6 (5,6) 0,974 0,004 0,010
3. 3 - combination of inguinal access with access to distal SFA and PA and tibial arteries 256 3 (1,2)
Total 761 31 (4,1)
Table 3
Results of various methods of lymphatic complication elimination (lymphorrhea) from
the inguinal access.
Method Number of patients (Abs.) Period of treatment. Me (days) P
Conservative 28 24 0,0119
Surgical 3 38
or by combination of this access with access to aorta and iliac arteries (5,6%). Infra-inguinal reconstructions were complicated by lymphatic leakage more rarely (1,2%).
Among the patients with lymphatic complications most patients (28 patients) were treated conservatively, and three patients were exposed to the surgical liquidation of the complication. There was revealed a statistically significant increase of the treatment period of patients which had a surgical method of lymphorrhea elimination (Table 3).
Discussion of results
Anatomical predisposition connected with the assembly of lymphatic vessels and nodes in the region of femoral triangle creates the risk of their injure during inguinal access [8]. The frequency of this complication, according to literature, varies from 1,1% to 4,6% [5.8.9.10.11]. In our research lymphorrhea was registered in 4,1% of patients, which comparable to the presented data of literature.
The formation of lymphatic fistula depends on the technique of the inguinal access to the vessels and contraction of the surgical wound. For the prevention of this complication during suture and also by the surgical treatment of lymphatic fistula fibrin glue is used. Randomized clinical study performed in Switzerland by L. Giovannacci in 2002 demonstrated high effectiveness of the method [12]. Some authors use topical antibiotics (doxycycline) or X-ray irradiation for the lymphorrhea elimination [9,14]
By intensive discharge of lymph out of fistula and absence of the effect of conservative treatment it is recommended to carry various surgical operations. Among them it is offered to use muscle flaps, direct operaion on lymphatic vessels or bandaging of lymphatic collectors [3,13]. For the visualization of injured lymphatic collectors it is recommended to use regional induction of coloring agent [15].
The leakage of lymph increases the risk of infection in the inguinal area, especially by the implementation of synthetical conduits [5,16,17,18]. During our observations in patients with lymphatic
fistulas there was registered the infection of prosthesis or in the zone of operated artery. In the area of fistulous tract there was observed the leakage of sterile lymph, which did not linger in tissues. Probably, the creation of conditions of sufficient drainage minimizes the risk of infection development. The conservative approach, used for the liquidation of complication, consisted in daily (sometimes two times a day) bandaging creating the conditions for good leakage of lymph. By the implementation of such method there was no need in using negative pressure systems for active lymph aspiration [19].
There is still no distinct tactics of treatment of postsurgical inguinal lymphorrhea. In the 1990s of the previous century there were published the results of the researches which declared various approaches to the treatment of lymphatic fistulas. The best results of surgical approach are presented by Schwartz M.A. et al. [20]. The author used pre-surgical induction of coloring agent into the back of foot with further targeted ligation of lymphatic nodes in the inguinal area. The average period of hospital stay constituted 2,4 days for the group of operated patients compared to 19 days in the group of patients with conservative treatment. Such approach and good results of surgical treatment were later published by Steele S.R.et al.[21].
An individualized approach, combining bandaging and drainage in the liquidation of inguinal lymphatic complications, is suggested by Tyndall S.H. et al. [22]. High effectiveness of the drainage technology, which can be referred to the conservative direction, is reported in the observational research conducted in the department of vascular surgery of the University of Brussels [7].
In our research the period of liquidation of the lymphatic fistula turned out to be statistically shorter by the conservative type of treatment. Actually, in three patients the active surgical approach, connected with a recurrent surgery in the inguinal area and bandaging of lymphatic nodes, was not accompanied by quick recovery. Drainage and other conservative methods were continued to be used in these patients, which did
not lead to the reduction of treatment period.
Lymph leakage was registered more often after the isolated inguinal access or aorto-ileum-femoral reconstruction. This is connected with the fact, that these groups, especially by isolated inguinal access, included patients with recurrent operations. Such dependence of lymphorrhea frequency on the combination of inguinal access was discovered by Tyndall S.H. et al. [22].
Conclusions
1. Lymphorrhea of inguinal access after reconstructive operations on arteries in registered in 4,1% of patients and occurs more often after the isolates inguinal access and or aorto-ileum-femoral reconstruction in patients with recurrent operations.
2. Conservative approach with active drainage of the wound is the method of choice for the treatment of postsurgical lymphorrhea after inguinal access in patients with lower limb vessel pathology.
References
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Contacts:
656038, Barnaul, Lenina Prospect, 40. Altai State Medical University. Tel.:: (3852) 201256 Email: xorev-ng@mail.ru
