Lymphocele

A lymphocele is a collection of lymphatic fluid within the body not bordered by epithelial lining.^[1] It is usually a surgical complication seen after extensive pelvic surgery (such as cancer surgery) and is most commonly found in the retroperitoneal space. Spontaneous development is rare.^[2]

Etiology

As already noted by Mori in 1955, the risk of the development of a lymphocele is positively correlated to the extent of the removal of lymphatic tissue during surgery (lymphadenectomy).^[3] Surgery destroys and disrupts the normal channels of lymph flow. If the injury is minor, collateral channels will transport lymph fluid, but with extensive damage, fluid may accumulate in an anatomic space resulting in a lymphocele.^[4] Typical operations leading to lymphocysts are renal transplantation and radical pelvic surgery with lymph node removal because of prostatic or gynecologic cancer.^[5] Other factors that may predispose of lymphocele development are preoperative radiation therapy, heparin prophylaxis (used to prevent deep vein thrombosis), and tumor characteristics.^[1] After radical surgery for cervical and ovarian cancer studies with follow-up CT found lymphoceles in 20% and 32%, respectively.^[6] Typically they develop within 4 months after surgery.^[7]

Symptoms

Many lymphoceles are asymptomatic. Larger lymphoceles may cause symptoms related to compression of adjacent structures leading to lower abdominal pain, abdominal fullness, constipation, urinary frequency, and edema of the genitals and/or legs. Serious sequelae could develop and include infection of the lymphocele, obstruction and infection of the urinary tract, intestinal obstruction, venous thrombosis, pulmonary embolism, chylous ascites and lymphatic fistula formation.^[1] On clinical examination the skin may be reddened and swollen and a mass felt. Ultrasonography or CT scan will help to establish a diagnosis. Other fluid collections to be considered in the differential diagnosis are urinoma, seroma, hematoma, as well as collections of pus. Also, when lower limb edema is present, venous thrombosis needs to be considered.^[8]

Management

It has been suggested that suction drains placed during surgery and non-peritonisation (not closing the posterior peritoneum) may reduce the possibility of lymphocele development. Smaller lymphoceles can be managed expectantly, and many lesions will regress over time.^[2] For symptomatic lesions a number of approaches are available and include fine needle aspiration with US or CT guidance, catheter insertion and drainage (with possible use of sclerosants), and surgical drainage.^[2][5]

References

1. 1 2 3 Metcalf KS, Peel KR (1993). "Lymphocele". Annals of the Royal College of Surgeons of England. 75: 387–392. 
2. 1 2 3 de Oliveira Goes Junior AM, Haber Jeha SA (2012). "Idiopathic Lymphocele: A possible Diagnosis for Infraclavicular Masses". Case Reports in Surgery. 2012: 1. doi:10.1155/2012/593028. 
3. ↑ Mori N (1955). "Clinical and experimental studies on so called lymphocyst which develops after radical hysterectomy in cancer of the uterine cervix". J Jpn Obstet Gynecol Soc. 2: 178. 
4. ↑ White M, Mueller PR, Ferrucci JT, et al. (1985). "Percutaneous drainage of postoperative abdominal and pelvic lymphoceles". Ajr. 145: 1065–1069. doi:10.2214/ajr.145.5.1065. 
5. 1 2 Kim JK, Jeong YY, Kim YH, Kim YC, Kang HK, Choi HS (1999). "Postoperative Pelvic Lymphocele: Treatment with Simple Percutaneous Catheter Drainage". Radiology. 212: 390–94. doi:10.1148/radiology.212.2.r99au12390. 
6. ↑ Petru E, Tamussino K, Lahousen M, Winter R, Pickel H, Haas J (1989). "Pelvic and paraaortic lymphocysts after radical surgery because of cervical and ovarian cancer". Am J Obstet Gynecol. 161: 937–41. doi:10.1016/0002-9378(89)90757-6. 
7. ↑ Cantrell CJ, Wilkinson EJ (1983). "Recurrent squamous cell carcinoma of the cervix within pelvic-abdominal lymphocysts". Obstet Gynecol. 62: 530–4. 
8. ↑ McCullough CS, Soper NJ (1991). "Laparoscopic drainage of a post transplant lymphocele". Transplantation. 51: 725–7. doi:10.1097/00007890-199103000-00034.