LYMPHOCELE AFTER RENAL TRANSPLANTATION
GRIFFITHS ET ALll
LYMPHOCELE AFTER RENAL TRANSPLANTATION A. 6.GRIFFITHS, E. W. FLETCHER AND P. J. MORRIS Nuffield Department of Surgery Transplant Unit, University o f Oxford, Churchill Hospital, Oxford.
Lymphoceles occurred in 25 of 115 patients after renal transplantation in the Oxford Unit. Signs of obstruction or pressure were produced in 16 of these 25 patients (15%), while nine were detected on a routine ultrasoundscan. The 16 symptomatic lymphoceleswere treated successfully by aspiration or surgical fenestration into the peritoneal cavity. Of the possible causes examined, diathermy and division of iliac lymphatics seemed to be the most likely reason for this high incidence. Since a technique of ligating or clipping the iliac lymphatics has been adopted, no lymphoceles have occurred in the subsequent 70 transplants.
A LYMPHOCELE, a collection of lymph in the renal transplant wound, is not uncommon after renal transplantation, the reported incidence ranging froin 2% to 28% (Schweizer et alii, 1972; Morley et alii, 1975). A lymphocele often presentsacutely with one or several of the following: unilateral oederna of the leg on the side of the collection, frequency and even strangury, diarrhoea, and deterioration of renal function. Deterioration in renal function may occur in the absence of the above signs, and so a lymphocele represents an important possibility in the differential diagnosis of rejection (Rashid et alii, 1974). Not all lymphoceles cause obstructive symptoms, and some may disappear spontaneously (Olsson et alii, 1978). In the Oxford Transplant Unit there has been a relatively high incidence of lymphoceles. This has enabled us to examine the factors that may be responsible as well as their response to treatment by aspi rat ion. PATIENTS
One hundred and ten patients who had received a kidney at least one year before this analysis and in whom the graft had remained insitu beyond the 14th day were included in the analysis. Lymphoceles occurred in 25 patients (22%); 16 of these patients (15%) were symptomatic and required treatment of the lymphocele, while in nine patients the lymphocele was detected by ultrasonicscanning as part of a routine investigation. Reprints: Professor Peter J Mori is University of Oxford, Nuffield Department of Surgery, John Radciiffe Hospital, Headrington, Oxford, OX390U. England.
626
Clinical Features The presenting features are shown in Table 1. A swelling was palpable in 10 of the 16 patients, and leg oedema was seen in six. Urinary frequency wasa complaint in two patients. There had been a deterioration in renal function in six patients. Diagnosis was confirmed by ultrasonic scanning in all patients, whilst an intravenous pyelogram showed distortion of the bladder or obstruction of the ureter in six patients. I n those patients with oedema of the leg venography demonstrated pressure on the iliac vein on the side of the lesion. Treatment Only lymphoceles producing clinical features were treated. The first treatment in 10 patients was aspiration with full sterile precautions under ultrasound control (Table 1). This was repeated as necessary, but if reaccumulation was rapid with further obstructive features then surgical drainage was carried out. Of the 10 patients treated byaspiration, five did not require subsequent surgical drainage. Of the six other patients treated before ultrasound controlled aspiration was available, four were drained surgically, one subsided spontaneously, and one patient underwent graft nephrectomy for rejection. Surgical drainage was achieved through a lower midline incision with the patient in the Trendelenburg position. The lymphocele was fenestrated into the peritoneal cavity and plugged with omentum to encourage lymphatic drainage. There has been no AUST. N.Z. J. SURG.VOL. 49 - No. 6,
DECEMBER,
1979
GRlFFlTHS ET ALll
LYMPHOCELE AFTER RENAL TRANSPLANTATION
TABLE 1 ~
Case No
Day of Presentation
1
147 64 39 21 21 36 19 51 113)' 37 ' ' 105 (24)' 22 35 18 14 98 95
2 3 4 5 6 7 8 9 10 11
12 14 l3 15 16
Deterioration in renal function
+
+
+
+
+ Spontaneous fluid leak
+
+
+
t
+ + + +
Spontaneous fluid leak
+
+
+
+ 10
Total
Treatment
Presenting Clinical Features Leg Oedema
Palpable Swelling
+
t
+ +
6
6
No of aspirations
Surgical fenestrations
Patients managed before ultrasound controlled aspiration available 1
Nn
3 3 3 5
No Yes Yes No
5
'Figures in brackets represent day of diagnosis of asymptomatic lymphoceles seen on ultrasound
morbidity following this procedure, and as yet no lymphoceles have recurred. Possible Aetiological Factors (7) Poor graft function. -There was no difference between graft function at one year or in incidence of graft failure in those patients with and those patients without lymphoceles. The number of rejection episodes was judged by the number of coursesof treatment (three twelve-hourly intravenous boluses of one gramme of methylprednisolone) given during the first 200 days after transplantation. The patients with a lymphocele received a mean of 2.0 coursesof treatment, compared with a mean of 2.9 courses in patients without a lymphocele. (2) Type of arterial anastomoSis. - No lymphoceles were seen in those patiens in whom anend-toend internal iliac to renal artery anastomosis was TABLE 2 The Incidence of Symptomatic Lymphoceles Related to the Type of Arterial Anastomosis End-to-end anastomosis End-to-side anastomosis -
23 67
0
16
P = 0 017 (Fisher's exact method)
TABLE 3 The Incidence of Symptomatic Lymphoceles Related to Drainage of the Wound. Wound drained Wound closed without drainage
Total
52
10
58
6
94
16
P = 0.09 (Fisher's exact method)
AUST. N.Z. J. SURG.VOL. 49 - No. 6, DECEMBER, 1979
performed (Table 2). We consider that the dissection with division of lymphatics in the iliac area is less with this type of anastomosis than with the more commonly practised end-to-side anastomosis of renal artery to common or external iliac arteries. (3) Wound drainage. -The wound was drained in approximately half the cases, but no difference in the incidence of lymphocele appeared to be associated with drainage (Table 3). DISCUSSION
There has been a relatively high incidence (22%) of lymphoceles following transplantation in the Oxford Unit. The source of lymph is considered to be the host lymphatics. This has been demonstrated by lymphangiography (Koehler, 1972), and recovery of labelled colloid (technicium sulphate) from a lymphocele after injection into the foot (Ward et alii, 1978). However, it is known that a renal allograft both in the sheep (Pederson and Morris, 1970) and in man (Hamburger et alii, 1971) will produce vast amounts of lymph from the unligated lymphatics of the kidney in the first week following transplantation. Thus it ispossiblethat thismay bethesourceof some lymphoceles, especially those that occur early after transplantation. However, if we accept that in general lymphoceles arise from host lymphatics, then a technical cause must be sought. Our demonstration that lymphoceles did not occur afteranastomosis of the renal to the internal iliac artery, where dissection and division of lymphatics are minimal, does suggest a technical fault. This may be related to the custom in this unit of using diathermy to coagulate lymphatics before dividing them. Although appropriate for small blood vessels where 627
LYMPHOCELE AFTER RENAL TRANSPLANTATION
coagulation occurs, this might be inappropriate for lymphatics, as the coagulated ends may slough off, allowing lymph to drain freely into the wound. Certainly it does seem that units that do not divide lymphatics (Calne, personal communication) or ligate divided lymphatics (Schweizer et alii, 1972) have a low incidence of lymphoceles. There is no evidence in our study to suggest that wound drainage after transplantation has any effect on the development of lymphoceles. In view of these findings we have changed our technique and now ligate or clip all divided lymphatics rather than use diathermy. Since adopting this approach we have not had a further instance of a lymphocele in the last 70 renal transplants. If a lymphocele does produce clinical features, then aspiration under ultrasound control should be the first line of treatment. Surgical fenestration into
GRlFFlTHS ET ALll
the peritoneal cavity is reserved for those cases not resolving after several aspirations. No treatment is required for the asymptomatic lymphocele, as many of these will resolve (Morley et alii, 1975). REFERENCES HAMBURGER,J..
BANKIR, L.. DEBRAY-SACHS M and AUVERT, J. (1971), Nature (Lond.), 232: 633. KOEHLER.P. R. (1972). Lymphology. 5: 61. MORLEY, P., BARNETT. E. and BELL,P. R. F. (1975). Cltn. Radio/. 26: 199 OLSSON. C. A,. WILLISHER. M K , FILOSOS.A. M. and CHO. S. I . (1978). Transpiantation Proceedtngs, 8. 150. PEDERSON, N. C. and MORRIS, B (1970), J. exp Med.. 131' 936 RASHID, A., DOSEN. G , COUTURE, R.. MCKAY. D. and WELLINGTON, R. (1974). J Urol. fSaltimore), 111, 145. SCHWEIZER. R T.. CHO, S., KOUNTZ. S. L. and BELZER. F. 0 . (1972), Arch. Surg. 104: 42. WARO, K., KLINGENSMITH, W. C., STREIOFF, S. and WAGNER, H. N., Jnr. (1978), Transplantation, 25: 346. DIMITRIL+A.,
AUST. N.Z. J. SURG.VOL. 49
-
No. 6, DECEMBER, 1979
GRIFFITHS ET ALll
LYMPHOCELE AFTER RENAL TRANSPLANTATION A. 6.GRIFFITHS, E. W. FLETCHER AND P. J. MORRIS Nuffield Department of Surgery Transplant Unit, University o f Oxford, Churchill Hospital, Oxford.
Lymphoceles occurred in 25 of 115 patients after renal transplantation in the Oxford Unit. Signs of obstruction or pressure were produced in 16 of these 25 patients (15%), while nine were detected on a routine ultrasoundscan. The 16 symptomatic lymphoceleswere treated successfully by aspiration or surgical fenestration into the peritoneal cavity. Of the possible causes examined, diathermy and division of iliac lymphatics seemed to be the most likely reason for this high incidence. Since a technique of ligating or clipping the iliac lymphatics has been adopted, no lymphoceles have occurred in the subsequent 70 transplants.
A LYMPHOCELE, a collection of lymph in the renal transplant wound, is not uncommon after renal transplantation, the reported incidence ranging froin 2% to 28% (Schweizer et alii, 1972; Morley et alii, 1975). A lymphocele often presentsacutely with one or several of the following: unilateral oederna of the leg on the side of the collection, frequency and even strangury, diarrhoea, and deterioration of renal function. Deterioration in renal function may occur in the absence of the above signs, and so a lymphocele represents an important possibility in the differential diagnosis of rejection (Rashid et alii, 1974). Not all lymphoceles cause obstructive symptoms, and some may disappear spontaneously (Olsson et alii, 1978). In the Oxford Transplant Unit there has been a relatively high incidence of lymphoceles. This has enabled us to examine the factors that may be responsible as well as their response to treatment by aspi rat ion. PATIENTS
One hundred and ten patients who had received a kidney at least one year before this analysis and in whom the graft had remained insitu beyond the 14th day were included in the analysis. Lymphoceles occurred in 25 patients (22%); 16 of these patients (15%) were symptomatic and required treatment of the lymphocele, while in nine patients the lymphocele was detected by ultrasonicscanning as part of a routine investigation. Reprints: Professor Peter J Mori is University of Oxford, Nuffield Department of Surgery, John Radciiffe Hospital, Headrington, Oxford, OX390U. England.
626
Clinical Features The presenting features are shown in Table 1. A swelling was palpable in 10 of the 16 patients, and leg oedema was seen in six. Urinary frequency wasa complaint in two patients. There had been a deterioration in renal function in six patients. Diagnosis was confirmed by ultrasonic scanning in all patients, whilst an intravenous pyelogram showed distortion of the bladder or obstruction of the ureter in six patients. I n those patients with oedema of the leg venography demonstrated pressure on the iliac vein on the side of the lesion. Treatment Only lymphoceles producing clinical features were treated. The first treatment in 10 patients was aspiration with full sterile precautions under ultrasound control (Table 1). This was repeated as necessary, but if reaccumulation was rapid with further obstructive features then surgical drainage was carried out. Of the 10 patients treated byaspiration, five did not require subsequent surgical drainage. Of the six other patients treated before ultrasound controlled aspiration was available, four were drained surgically, one subsided spontaneously, and one patient underwent graft nephrectomy for rejection. Surgical drainage was achieved through a lower midline incision with the patient in the Trendelenburg position. The lymphocele was fenestrated into the peritoneal cavity and plugged with omentum to encourage lymphatic drainage. There has been no AUST. N.Z. J. SURG.VOL. 49 - No. 6,
DECEMBER,
1979
GRlFFlTHS ET ALll
LYMPHOCELE AFTER RENAL TRANSPLANTATION
TABLE 1 ~
Case No
Day of Presentation
1
147 64 39 21 21 36 19 51 113)' 37 ' ' 105 (24)' 22 35 18 14 98 95
2 3 4 5 6 7 8 9 10 11
12 14 l3 15 16
Deterioration in renal function
+
+
+
+
+ Spontaneous fluid leak
+
+
+
t
+ + + +
Spontaneous fluid leak
+
+
+
+ 10
Total
Treatment
Presenting Clinical Features Leg Oedema
Palpable Swelling
+
t
+ +
6
6
No of aspirations
Surgical fenestrations
Patients managed before ultrasound controlled aspiration available 1
Nn
3 3 3 5
No Yes Yes No
5
'Figures in brackets represent day of diagnosis of asymptomatic lymphoceles seen on ultrasound
morbidity following this procedure, and as yet no lymphoceles have recurred. Possible Aetiological Factors (7) Poor graft function. -There was no difference between graft function at one year or in incidence of graft failure in those patients with and those patients without lymphoceles. The number of rejection episodes was judged by the number of coursesof treatment (three twelve-hourly intravenous boluses of one gramme of methylprednisolone) given during the first 200 days after transplantation. The patients with a lymphocele received a mean of 2.0 coursesof treatment, compared with a mean of 2.9 courses in patients without a lymphocele. (2) Type of arterial anastomoSis. - No lymphoceles were seen in those patiens in whom anend-toend internal iliac to renal artery anastomosis was TABLE 2 The Incidence of Symptomatic Lymphoceles Related to the Type of Arterial Anastomosis End-to-end anastomosis End-to-side anastomosis -
23 67
0
16
P = 0 017 (Fisher's exact method)
TABLE 3 The Incidence of Symptomatic Lymphoceles Related to Drainage of the Wound. Wound drained Wound closed without drainage
Total
52
10
58
6
94
16
P = 0.09 (Fisher's exact method)
AUST. N.Z. J. SURG.VOL. 49 - No. 6, DECEMBER, 1979
performed (Table 2). We consider that the dissection with division of lymphatics in the iliac area is less with this type of anastomosis than with the more commonly practised end-to-side anastomosis of renal artery to common or external iliac arteries. (3) Wound drainage. -The wound was drained in approximately half the cases, but no difference in the incidence of lymphocele appeared to be associated with drainage (Table 3). DISCUSSION
There has been a relatively high incidence (22%) of lymphoceles following transplantation in the Oxford Unit. The source of lymph is considered to be the host lymphatics. This has been demonstrated by lymphangiography (Koehler, 1972), and recovery of labelled colloid (technicium sulphate) from a lymphocele after injection into the foot (Ward et alii, 1978). However, it is known that a renal allograft both in the sheep (Pederson and Morris, 1970) and in man (Hamburger et alii, 1971) will produce vast amounts of lymph from the unligated lymphatics of the kidney in the first week following transplantation. Thus it ispossiblethat thismay bethesourceof some lymphoceles, especially those that occur early after transplantation. However, if we accept that in general lymphoceles arise from host lymphatics, then a technical cause must be sought. Our demonstration that lymphoceles did not occur afteranastomosis of the renal to the internal iliac artery, where dissection and division of lymphatics are minimal, does suggest a technical fault. This may be related to the custom in this unit of using diathermy to coagulate lymphatics before dividing them. Although appropriate for small blood vessels where 627
LYMPHOCELE AFTER RENAL TRANSPLANTATION
coagulation occurs, this might be inappropriate for lymphatics, as the coagulated ends may slough off, allowing lymph to drain freely into the wound. Certainly it does seem that units that do not divide lymphatics (Calne, personal communication) or ligate divided lymphatics (Schweizer et alii, 1972) have a low incidence of lymphoceles. There is no evidence in our study to suggest that wound drainage after transplantation has any effect on the development of lymphoceles. In view of these findings we have changed our technique and now ligate or clip all divided lymphatics rather than use diathermy. Since adopting this approach we have not had a further instance of a lymphocele in the last 70 renal transplants. If a lymphocele does produce clinical features, then aspiration under ultrasound control should be the first line of treatment. Surgical fenestration into
GRlFFlTHS ET ALll
the peritoneal cavity is reserved for those cases not resolving after several aspirations. No treatment is required for the asymptomatic lymphocele, as many of these will resolve (Morley et alii, 1975). REFERENCES HAMBURGER,J..
BANKIR, L.. DEBRAY-SACHS M and AUVERT, J. (1971), Nature (Lond.), 232: 633. KOEHLER.P. R. (1972). Lymphology. 5: 61. MORLEY, P., BARNETT. E. and BELL,P. R. F. (1975). Cltn. Radio/. 26: 199 OLSSON. C. A,. WILLISHER. M K , FILOSOS.A. M. and CHO. S. I . (1978). Transpiantation Proceedtngs, 8. 150. PEDERSON, N. C. and MORRIS, B (1970), J. exp Med.. 131' 936 RASHID, A., DOSEN. G , COUTURE, R.. MCKAY. D. and WELLINGTON, R. (1974). J Urol. fSaltimore), 111, 145. SCHWEIZER. R T.. CHO, S., KOUNTZ. S. L. and BELZER. F. 0 . (1972), Arch. Surg. 104: 42. WARO, K., KLINGENSMITH, W. C., STREIOFF, S. and WAGNER, H. N., Jnr. (1978), Transplantation, 25: 346. DIMITRIL+A.,
AUST. N.Z. J. SURG.VOL. 49
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No. 6, DECEMBER, 1979
