Lymphorrhea responds to negative pressure wound therapy
Article Outline
Lymphoceles and lymph fistulas are common complications of femoral exposure for vascular procedures. Three patients who required readmission after their vascular interventions were treated with negative pressure wound therapy. Once adequate control of the drainage was obtained, the patients were discharged home with a portable suction unit. The mean time to stop lymph leak was 14 days, and the mean length of hospital stay was 7.3 days. This method of management offers early control of fluid drainage, rapid control of the wound, earlier closure, and the potential for reduced length of stay. Patient acceptance and convenience may be enhanced by outpatient management and return to work in appropriately motivated individuals.
Lymphatic injury is a common cause of morbidity in the vascular patient. Lymphatic vessels are usually small and are infrequently visualized. Despite efforts to meticulously ligate lymphatic tissue, transection of adjacent lymphatics will occasionally occur during vascular exposures because they are anatomically located close to major vessels, clinically appearing as lymphocele or lymph fistula in 1% to 4% of femoral dissections.1
Lymphocele is a cystic collection of lymphatic fluid from a disrupted lymphatic channel that forms a pocket in the soft tissue of the healing wound. Continued fluid accumulation in fresh wounds may cause wound disruption and lymphorrhea. Continued leakage constitutes lymph fistula. Lymphoceles and lymph fistulas of the femoral regions have been reported after lymph node biopsy, arterial reconstruction, vascular cannulation, saphenous vein harvest, and other procedures.2 Any dissection in the region of the femoral neurovascular bundle can lead to the transection of the lymphatic channels.
Uncontrolled lymphatic drainage can be the source of significant morbidity for the patient, and wound infection may occur in up to 57%.3 Lymph leaks are difficult to manage and can result in prolonged hospital stays of up to a month.4 Secondary wound infection may be devastating when prosthetic material is present. Exposure of either autogenous or synthetic grafts may result in breakdown with bleeding, infection, and loss of the vascular reconstruction, life, and/or limb.
Many modes of therapy have been described (Fig 1). A novel mode of therapy is the use of negative pressure wound therapy (NPWT) devices to treat this problem. We successfully managed three patients with lymphatic leaks using NPWT.
Fig 1.
Current modes of therapy for femoral lymph leaks with proposed role of negative pressure wound therapy (NPWT).
Case report
Patient 1
PS is an 88-year-old man who was referred for evaluation of a pulsatile suprapubic mass. An infrarenal abdominal aortic aneurysm had been repaired with an aortoaortic tube graft more than decade previously. Duplex ultrasound imaging and CT scans demonstrated a 6-cm anastomotic pseudoaneurysm at the distal anastomosis.
Bilateral longitudinal femoral arteriotomies were performed and the pseudoaneurysm was successfully excluded with a bifurcated endovascular graft. On postoperative day (POD) 6, spontaneous drainage of copious, clear, serous lymphatic fluid was noted from the left femoral incision. The patient was placed on bed rest with compression dressings applied to the groin. The lymph leak continued.
On POD 11, we explored the wound after injections of isosulfan blue dye in the distal thigh an hour before the start of the procedure; however, this failed to localize the leaking lymphatic channels. Copious, serous drainage continued. The wound was subsequently treated with NPWT. Lymphatic drainage ceased after 19 days of therapy. Although this therapy could have been delivered at his home, he remained in the hospital for social reasons. The lymph leak completely resolved, and the wound has remained closed with no ultrasound evidence of lymphocele by 15 months (Fig 2).
Fig 2.
Patient 1. A, Lymphorrhea left femoral wound. B, Negative pressure wound therapy in place. C, Granulation tissue. D, Wound healed.
Patient 2
RF is 52-year-old man who was treated several years previously with abdominoperineal resection and pelvic irradiation for colon cancer. An acute left iliofemoral venous thrombosis developed after placement of a prosthetic penile implant. He returned to the operating room where the reservoir for the implant was revised. The thrombosis manifested as diffuse limb edema, pain, cyanosis, and discoloration. Venous thrombectomy through a longitudinal infrainguinal incision produced immediate relief of pain, edema, and cyanosis. Initially managed with intravenous heparin, he was discharged home after achieving appropriate Coumadin (Bristol-Myers Squibb, New York, NY) anticoagulation.
The patient returned to the clinic on POD 13 with leakage of lymph from the thrombectomy incision. He was subsequently taken to the operating room in attempts to ligate the draining lymphatics with the assistance of distal limb isosulfan blue dye injections in between the first and second toes and third and fourth toes. Despite injection 30 minutes before the operation and waiting for 30 minutes in the operating room, no clearly draining blue lymphatics were seen. The tissue at the base of the wound where the lymph leak was suspected was ligated. A suction drain was placed and the wound was closed. He was discharged home, but the drain was dislodged accidentally at home.
Although these attempts to control the lymph leak were unsuccessful, a clean, open wound was achieved. NPWT was applied to control the drainage and he was discharged home 5 days later. This was facilitated by home nurse monitoring of a portable NPWT unit changed every 3 days. This patient was self employed and returned to work while wearing the portable NPWT dressing. His lymph leak ceased after 12 days of NPWT and has not recurred. There was no evidence of lymphocele on ultrasound imaging after 11 months.
Patient 3
At age 72, JR had an uneventful, elective, endovascular repair of an infrarenal 6.2-cm abdominal aortic aneurysm via bilateral longitudinal femoral incisions. Seven days after discharge home, he returned with fever of 102°F and drainage of clear, serous fluid from left femoral incision. The right femoral incision healed without complications. The left wound was opened at the bedside and was managed locally for 2 days with wet-to-damp dressing changes and intravenous antibiotics. Once the fever resolved and the wound was clean and clear of infection, a NPWT dressing was applied.
He was discharged home again 5 days later. This was facilitated by home nurse monitoring of a portable NPWT unit changed every 3 days. His lymph leak stopped after 11 days of NPWT and has not recurred. There was no evidence of lymphocele on ultrasound imaging after 12 months.
Discussion
Many modes of therapy have been proposed (Fig 1) for treatment of this problem. Nonoperative recommendations have included bed rest, prophylactic antibiotics, and pressure dressings. This management resulted in extended length of hospital stay, increased cost, patient immobility, and risk of underlying wound or graft infection. Other nonoperative modalities that have been tried with modest success include multiple aspirations of the lymphatic cavity, instillation of sclerosing agents, and administration of radiation therapy to the region.3, 4
Operative modalities have been advocated by some authors as an ideal approach to this problem. A few authors recommend ligation of leaking lymphatics with the assistance of intraoperative lymphatic mapping.3, 5, 6, 7 A more aggressive approach for the exposed synthetic graft is a muscle flap to cover the graft. Although this requires an extensive dissection and another operation, it is the most effective treatment, with prevention of infection and anastomotic breakdown.8
Fleischmann et al9 described the concept of using controlled subatmospheric pressure to treat open or infected wounds in 1993. The negative pressure wound care system was developed using the same principles by Argenta et al10 in 1995 (V.A.C. Therapy System, KCI, San Antonio, Tex). It has been shown to be superior to conventional dressings in the management of complex wounds.
Initial studies with NPWT dressings in animal laboratory animals showed that it increased the granulation tissue in the wound by 103.4% ± 35.3%. This is postulated to be caused by the effects of suction on increased blood flow to the wound region, the removal of wound inhibiting factors such as metalloproteases from the wound, and finally, the cellular response to increased stress in the wound. The NPWT system has also been shown to decrease the bacterial count in the grossly infected wound to <105 organisms per gram of tissue within 4 to 5 days. By removing interstitial fluids that develop with edema around the wound site, it also decreases the distance from blood vessels to the wound and therefore improves oxygen and nutrient delivery and decreases the distance the white blood cells have to travel to reach the wound site.11
The one disadvantage of the NPWT system is that the suction apparatus is usually bulky, and although it is good for immobile patients, it hinders ambulatory patients. To allay this problem, a portable, battery-powered suction unit is now commercially available (Fig 3). This simplifies the care of complex wounds in the outpatient setting.
Fig 3.
Patient 2. A, Portable negative pressure wound therapy allows ambulatory therapy. B, Granulating wound after treatment with portable negative pressure wound therapy.
The incidence of femoral wound infection is 1% to 2% in femoral dissections. These infections are potentially disastrous. This is especially true in cases where prosthetic grafts are used in the wound. Dosluoglu et al12 applied NPWT successfully in management of wounds with exposed prosthetic material. This was achieved only if the anastomosis was not exposed. Presumably, a number of these exposed and infected grafts would have required resection and revascularization. Their report demonstrates successful NPWT management of graft exposure and infection in the wound.
In this study, the effectiveness of NPWT was demonstrated in three patients by resolution of the lymphocele and cessation of the lymphatic drainage (Fig 4). Operative therapy failed to stop lymphatic drainage in the two patients that underwent this initial mode of therapy. Mean duration of therapy reported was 47.6 days for nonoperative therapy and 19.8 days for operative therapy. Our mean time for cessation lymphatic drainage was 14 days (Table). There were no infections after application of NPWT system, and in all cases, the wounds closed successfully without disruption of vascular repair. Wound infections have been reported to ensue in as many as 57% of incisions complicated by lymph fistula. Two patients were discharged home with the portable NPWT device, which enabled one patient to resume work.
Fig 4.
Patient 3. A and B, Duplex ultrasound imaging of the femoral region demonstrates the femoral artery and vein and the echolucent lymphocele. C, Resolution of the lymphocele after negative pressure wound therapy. FV, femoral vein.
Table. Summary of therapy for patients
| Patient | |||
|---|---|---|---|
| I | II | III | |
| Procedure | Endovascular AAA repair | Endovascular AAA repair | Thrombectomy of iliofemoral vein |
| Onset of lymph leak | POD 6 | POD 7 | POD 13 |
| Side of complication | Left | Left | Left |
| Clinical course | POD 11 | POD 16 | POD 13 debridement |
| NPWT commences | Re-op (lymphatic mapping + ligation) | Bedside wound drainage + antibiotics | POD 31 Re-op (lymph mapping + ligation) |
| POD 14 | POD 18 | POD 34 | |
| Days to stop lymph leak | 19 | 11 | 12 |
| LOS† (days) | 7 days⁎ | 7 days | 8 days |
| Infection | None | Yes (fever, ↑WBC on presentation) | None |
⁎Patient was ready for discharge at 7 days but remained 29 days for social reasons. |
†Length of hospital stay to care for fistula. |
Conclusion
Although many modes of therapy have been described for the treatment of lymph fistulas, no one mode has clearly emerged as the best solution. We successfully treated three patients with lymph leaks from their femoral dissection with negative pressure wound therapy. Although we present a small case series, we have demonstrated that NPWT resulted in rapid resolution of three lymph fistulas, was amenable to outpatient management, and decreased the time to closure compared with existing treatment options and without the morbidity of an operative procedure.
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Funding provided by Sigvaris Traveling Fellowship in Venous Disease.
Competition of interest: The authors have no financial ties with the NPWT product or the corporation manufacturing this product. This undertaking was not supported by the manufacturers of this product.
PII: S0741-5214(06)01973-2
doi:10.1016/j.jvs.2006.10.043
© 2007 The Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
