Treatment of postoperative inguinal lymphocele with fibrin glue injection: case report

Abstracts

O paciente desenvolveu linforragia na região inguinal direita, depois de ponte aorto-bifemoral com enxerto de dácron®. Não respondeu ao tratamento conservador com cuidados locais e compressão. Foi realizado exame de ultra-sonografia Doppler, que evidenciou grande linfocele (6,4 x 3,36 x 6,1 cm), tratada pelo esvaziamento da loja por aspiração e injeção de cola de fibrina (1,6 mL) em seu interior. O paciente se recuperou sem intercorrências e sem recidiva, após 3 meses de seguimento.

Linfocele; adesivo tecidual de fibrina; cirurgia vascular

CASE REPORT

Treatment of postoperative inguinal lymphocele with fibrin glue injection: case report

Priscila Nunes Boaventura; Marcone Lima Sobreira; Winston Bonetti Yoshida; Hamilton Almeida Rollo

Hospital das Clínicas, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista Júlio de Mesquita Filho, Botucatu, SP, Brazil

^{Correspondence}

ABSTRACT

The patient developed lymphatic drainage in the right groin after an aortobifemoral bypass with Dacron^® graft. Conservative treatment with local wound care and compression was unsuccessful. Duplex scan showed a 6.4 x 3.36 x 6.1 cm lymphocele, which was treated by aspiration and injection of fibrin glue (1.6 mL). The patient recovered uneventfully and without recurrence after a 3-month follow-up.

Keywords: Lymphocele, fibrin tissue adhesive, vascular surgery.

Introduction

Lymphatic drainage from the groin resulting from lymphatic vessel lesion is a frequent complication after exposure of the common femoral artery in patients submitted to infrainguinal revascularization,¹ which usually occurs in 0.8-6.4% of cases.² Non-extravasated lymph is often restricted by neighboring tissues, and the inflammatory process triggered by its presence favors the development of a capsule around it, which originates a lymphocele. In general, small lymphoceles spontaneously regress within 2 to 3 days, and can be followed clinically.¹ However, increased lymphatic pressure, inflammation, infection and presence of grafts may lead to increased graft volume, requiring its treatment to avoid infection of operative wound and local vascular repair.

Some studies show successful use of fibrin glue in the treatment of inguinal pseudoaneurysms after femoral punctures and catheterizations.^3,4 Other studies also showed use of fibrin glue to prevent and treat lymphatic complications, especially after radical lymphadenectomy, as well as the apparent advantage in reducing incidence of postoperative (PO) surgical infection.^5-7

This case report aims at showing the efficacy of fibrin glue as a treatment option for lymphatic drainage and lymphocele, after femoral artery surgery in the inguinal region.

Case report

A 75-year-old male patient, hypertensive, dyslipidemic, ex-smoker and ex-alcoholic had been presenting intermittent claudication for 300 m for 5 years, which worsened for 50 m followed by spontaneous appearance of ulceration in the 5th right toe without healing for 7 months. On physical examination, there was absence of all lower limb pulses. Doppler showed absence of blood flow signal in the popliteal and distal arteries bilaterally. Arteriography showed occlusion in the aorto-iliac territory.

He was submitted to aorto-bifemoral bypass with bifurcated Dacron^® graft, 16 x 8 mm, presenting spontaneous drainage of thick and purulent secretion in the right inguinal region in the 11th PO day, associated with surgical incision hyperemia. Secretion culture was performed, showing Staphylococcus aureus sensitive to vancomycin.^® After antibiotic therapy was started, there wasexpressive improvement in the infection, but not in local drainage. On the 24th PO day, the patient presented bulging in the right inguinal region, with spontaneous lymph flow through the surgical scar. Doppler ultrasound revealed collection of fluid density and no flow in the right inguinal region (6.4 cm x 3.36 cm x 6.1 cm), with diagnosis of lymphocele. Using the technique described for closing arterial pseudoaneurysms, we tried to close the drainage hole guided by ultrasound: local asepsis + manual expression + percutaneous needle aspiration (around 40 mL) with lymphadenectomy and injection of 1.6 mL fibrin glue (Beriplast^® P — ZLB Behring) at the exit site, followed by manual compression for 15 minutes and placement of local weight, which remained for 24 hours. After that period, there was no bulging nor local lymphatic drainage (spontaneous or at local expression). Another Doppler ultrasound showed small exit site distally to the surgical incision, but without communication with the previous drainage hole. A new puncture and aspiration of 10 mL of clear lymph without grumes was then performed, with emptying and guided compressive dressing. There was no formation of a new collection or development or local phlogistic signs.

Ninety days after the surgery, the patient was asymptomatic, without bulging (Figure 1) nor lymph drainage in the right surgical scar and without local phlogistic signs. Control Doppler ultrasound did not show collection at the site (Figure 2).

Discussion

Treatment of lymphoceles that are not clinically reabsorbed is usually surgical.² Possibilities for surgical intervention range from surgical drainage and cauterization of lymphatic vessels to surgical lymphatic excision and ligation of lymphatic vessels.⁸

Fibrin glue has been successfully used to close pseudoaneurysms of the femoral artery after punctures or catheterizations,^3,4,9 or even in arterial anastomoses.¹⁰ Some studies also showed the use of fibrin glue to prevent and treat lymphatic complications, especially after radical lymphadenectomy. Giovannacci et al. performed a prospective study in patients submitted to arterial revascularization, obtaining lower number of lymphatic complications in the group receiving fibrin glue (p = 0.019).¹

The lymph has components that promote its coagulation. In this sense, introduction of procoagulating substances could accelerate this process, which is useful for reducing drainage, thus avoiding major surgical interventions for the patient, increasing morbidity rates. Besides this procoagulating effect, a probable mass glue effect (after constituted) could work as a buffer on lymphocele drainage holes, contributing to reduction and cessation of lymphatic drainage.

Success of fibrin glue therapy also depends on local compression, initially manual and then maintained with inguinal weight. This type of treatment for lymphocele after vascular surgery using femoral approach was not found in the literature. However, in case of signs suggesting infection in the lymphocele area, we believe that, similar to the arterial pseudoaneurysm, treatment with fibrin glue injection is also contraindicated due to possibility of maintaining the infectious agent at the site.

In summary, we suggest that, in situations in which presence of lymphatic drainage could compromise revascularization, a choice could be emptying followed by fibrin glue injection + local compression. It cannot be forgotten that, in most cases, use of a careful surgical technique and postoperative cares may be sufficient to avoid this type of complication.

References

Manuscript received March 8, 2007, accepted May 21, 2007.

• 1. Giovannacci L, Renggli JC, Eugster T, Stierli P, Hess P, Gürke L. Reduction of groin lymphatic complications by application of fibrin glue: preliminary results of a randomized study. Ann Vasc Surg. 2001;15:182-5.
• 2. Pereira AH, Grudtner MA. Complicações não-infecciosas da cirurgia arteriais. In: Brito CJ, Duque A, Merlo I, Murilo R, Fonseca Filho VL. Cirurgia vascular. Rio de Janeiro: Revinter; 2002. p. 768-9.
• 3. Sadiq S, Ibrahim W. Thromboembolism complicating thrombin injection of femoral artery pseudoaneurysm: management with intraarterial thrombolysis. J Vasc Interv Radiol. 2001;12:633-6.
• 4. Morgan R, Belli AM. Current treatment methods for postcatheterization pseudoaneurysms. J Vasc Interv Radiol. 2003;14:697-710.
• 5. Waclawiczek HW, Pimpl W. [Lymph fistulae following lymph node dissections prevention and treatment using fibrin glue]. Chirurg. 1986;57:330-1.
• 6. Furrer M, Inderbitzi R, Nachbur B. [Does administration of fibrin glue prevent development of lymphoceles after radical lymphadenectomy?] Chirurg. 1993;64:1044-9.
• 7. Gilly FN, Francois Y, Sayag-Beaujard AC, Glehen O, Brachet A, Vignal J. Prevention of lymphorrhea by means of fibrin glue after axillary lymphadenectomy in breast cancer: prospective randomized trial. Eur Surg Res. 1998;30:439-43.
• 8. Shermak MA, Yee K, Wong L, Jones CE, Wong J. Surgical management of groin lymphatic complications after arterial bypass surgery. Plast Reconstr Surg. 2005;115:1954-62.
• 9. Pinto DM, Dias Jr. JO, Fonseca BLC, Moreialvar RD, Bez LG, Lopes CS. Experiência inicial com o uso de adesivo tissular contendo trombina para tratamento do pseudo-aneurisma femoral. J Vasc Bras. 2006;5:30-6.
• 10. Yoshida WB, Naresse LE, Rodrigues AC, Fabris VE, Angeleli AY. End-to-end arterial anastomosis with fibrin glue in larger arteries: histology, hydroxyproline concentration and tensile strength study in carotids of rabbits. Acta Cir Bras. 2002;17: 4-11.

Publication Dates

• Publication in this collection
  20 Sept 2007
• Date of issue
  June 2007

History

• Accepted
  21 May 2007
• Received
  08 Mar 2007