Ø A lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialized cover, usually occurring at a site of extensive surgical dissection. Post-transplant lymphocele has a reported incidence of 0.6-34%.
Ø The aetiology of lymphoceles may be categorised broadly based on surgical or medical risk factors. Among these, the most common are the surgical risk factors involving the donor and recipient operation
1. During donor kidney procurement, hilar lymphatics may be damaged either at the time of nephrectomy or during ‘back-table’ dissection
2. Laparoscopic donor nephrectomy has been implicated with a higher incidence of lymphocele compared to open nephrectomy
3. donor kidneys with complex arterial anatomy carried a higher risk of lymphocele
4. use of sirolimus was an independent risk factor for lymphocele formation
5. higher incidence of lymphocele with the use of rabbit antithymocyte globulin induction
6. use of low molecular weight heparin after transplantation.
7. Other risk factors implicated with lymphoceles include: increased recipient age, increased warm ischaemia time, acute tubular necrosis and delayed graft function, prolonged pre-transplant dialysis and retransplantation
Ø Clinical presentation: The vast majority of lymphoceles are asymptomatic and are detected as an incidental finding on imaging. Large lymphoceles may cause abdominal discomfort, pain, urgency (due to bladder compression) and backache (sacral nerve compression)
Ø The primary modality in diagnosis is imaging. USS can determine the collection as well as its dimensions, location in relation to the graft and possible effects on the graft vessels and ureter _ USS guided aspiration, and biochemical analysis of contained fluid allows
Ødifferentiation from urinary leak and urinoma.
Ø The vast majority of asymptomatic lymphoceles are self-limiting and do not require specific treatment. Symptomatic lymphoceles can be aspirated under USS guidance and remain the safest mode of intervention where needed.
level 5
Naglaa Abdalla
2 years ago
A lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialized cover, usually occurring at a site of extensive surgical dissection.
A peri-graft lymphocele post renal transplantation has different clinical presentations.
-It can be asymptomatic
-Pressure effects on the hilar vessels
-Pressure on the ureter
-Pressure on the recipient iliac vein
– compression of lymph drainage may lead to unilateral limb oedema, scrotal or vulval odema and deep vein thrombosis of the iliac veins.
Large lymphoceles may cause abdominal discomfort, pain, urgency and backache. Association with wound dehiscence can lead to sepsis or lympho-cutaneous fistula. DIAGNOSIS:
USS can determine the collection as well as its dimensions, location in relation to the graft and .
USS guided aspiration, and biochemical analysis of contained fluid. TREATMENT
The majority of asymptomatic lymphoceles are self-limiting and need only imaging follow up. If causing pressure effects then:
–Percutaneous aspiration and sclerotherapy
-Laparoscopic fenestration
-or open surgery
Radwa Ellisy
2 years ago
Introduction:
A lymphocele occurs as a result of extensive surgical dissection for the donor and recipient, it occurs in the form of fluid collection without epithelial lining. It occurs usually between 2-6 weeks but may occur before 2 ws and months later on
It may be presented as indolent collections incidentally found, or may cause graft dysfunction or sepsis.
It has a variable incidence 0.6% to 34%, lack of reporting indolent cases may have a role in this wide range.
Risk factors:
Surgical: the more dissection, the more incidence.
1- Damage to donor’s at the time of nephrectomy or during ‘back-table’ dissection.
2- Iliac vessels related lymphatic dissection.
3- Laparoscopic donor nephrectomy has a higher incidence than open nephrectomy.
4- Ipsilateral placement of the kidney and implantation to the common iliac vessels has lesser rates than contralateral iliac fossa placement and implantation to external iliac vessels compared to common iliac vessels.
Non-surgical risk factors:
The diabetic recipient, ADPKD recipient, obesity, and sirolimus use.
Clinical presentation
Mostly asymptomatic
According to its size, its relation to the graft,
– Close to hilar vessels may impair graft function +/- catastrophic renal artery or vein thrombosis in rare cases.
– Hydroureter or hydronephrosis if compress ureter.
– unilateral limb edema, scrotal or vulval edema, and deep vein thrombosis if compressed iliac veins.
– Abdominal discomfort, pain, urgency and backache with large lymphocele
– Sepsis if complicated
Diagnosis
By ultrasound: clear content if not complicated, echoic lesion if complicated by infection
Aspiration and biochemical analysis to differentiate from urine leak
Treatment:
Mostly self-limiting especially if not causing compression
Percutaneous aspiration and sclerotherapy: simple and safe +/- drain insertion
Laparoscopic fenestration: after the exclusion of infection, it would be drained intraperitoneally.
level of evidence: 5
Rehab Fahmy
2 years ago
Lymphocele : it is a collection of lymph that may occur 2-6 weeks after kidney transplantation
Pathophysiology: -ligation of lymphatic around iliac vessels. Risk Factors: Recipient DM , obesity , ADPKD , mTORi Diagnosis : Creatinine in drain ,creatinine in fluid aspirate + US DD: hematoma Complications: hydroureter ,hydronephrosis , DVT ,fistula Treatment:mainly conservative
A lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialized cover, usually occurring at a site of extensive surgical dissection. Post-transplant lymphocele has a reported incidence of 0.6-34%.
Risk factors
1- hilar lymphatics may be damaged either at the time of nephrectomy or during ‘back-table’
2- allograft and associated inflammatory processes increase lymph flow from the renal hilum as well as from the lymphatics around iliac vessels, resulting lymphocele formation due to lymph leakage
3- diabetes is an independent risk factor for lymphocele formation
4- Adult polycystic kidney disease
5- Obesity in the donor
6- use of low molecular weight heparin after transplantation.
7- the use of sirolimus, mycophenolate and prednisolone combination
8- acute rejection of the graft is an independent risk factor for the incidence of lymphocele
presentation
depending on the size and site, mostly asymptomatic. Pressure on the hilar vessels can lead to impaired graft function and may even lead to catastrophic renal artery or vein thrombosis in rare instances where it goes undetected. Pressure on the ureter may lead to hydroureter or hydronephrosis of the graft. Pressure on the recipient iliac vein or compression of lymph drainage may lead to unilateral limb oedema, scrotal or vulval oedema and deep vein thrombosis of the iliac veins.
Diagnosis
1st investigation include us followed by aspiration of fluid with analysis showing Similar Creatinine and Potassium to the Serum, CT Scan or MRI help in defining the anatomy and guiding the modality of treatment.
Treatment
Treatment is conservative for asymptomatic lymphocele with periodic us examination. Intervention depends on definitive pressure effects causing symptoms, graft dysfunction, evidence of sepsis or fistula formation.
This is a level V evidence article
Hamdy Hegazy
2 years ago
Please summarize this article Risk factors for lymphocele because of damaged lymphatics include: Laparoscopic donor nephrectomy, complex arterial donor kidneys, contra-lateral iliac fossa placement and implantation to external iliac vessels. Other non-surgical factors include Tacrolimus use, acute rejection, DM, obesity and polycystic kidneys in the recipients. Clinical presentation of lymphocele: asymptomatic in majority of cases, symptomatic compression effects: renal artery or vein thrombosis, Hydro-ureter or hydro-nephrosis, lower limb edema, scrotal or vulval edema and DVT of iliac veins. Large lymphoceles can cause abdominal pain, urgency (bladder compression) and backache (sacral nerve compression), wound dehiscence or lympho-cutaneous fistula. Diagnosis of Lymphocele: CT or USS guided aspiration of the collection fluid and check its serum creatinine and potassium to be compared to the serum. This fluid is to be sent for culture as well to rule out infection and abscess formation. Treatment of Lymphocele: most of them are self-limiting as long as there are no pressure symptoms. If there are pressure symptoms, they can be treated via: Intra-operative drain placement, or percutaneous aspiration and sclerotherapy or Open laparoscopic fenestration or open surgery What is the level of evidence provided by this article? Level V
Ahmed Omran
2 years ago
A lymphocele is an abnormal collection of lymphatic fluid without an epithelialized cover, usually occurring at a site with extensive surgical dissection.
Post-transplant lymphocele has incidence of 0.6-34%.
The incidence of symptomatic lymphocele is much less and has been found at a mean of 5.2% ;range 0.03- 26%.
The peak incidence time of lymphoceles has been reported at 6 weeks post-transplant.
Peri-graft lymphocele is common morbidity following renal Tr. However, the vast majority of cases remain asymptomatic and self-limiting. However, close surveillance is required to rule out pressure effects on the graft and possibility of secondary infection. Multiple risk factors have been reported which help in identifying patients at a higher risk of lymphocele. Symptomatic or complicated lymphoceles need urgent intervention with minimal negative impact to the graft as well as the patient. Small volume collections, if there is clinical indication, may be treated with percutaneous techniques to enhance resolution. Recurrent collections or large volume lymphoceles are optimally treated by laparoscopic fenestration into the peritoneal cavity. Open surgical de-roofing historical practice.
level 5 article.
Dalia Ali
2 years ago
In renal transplantation, a lymphocele may occur adjacent to the graft, due to multiple factors including damage to host retroperitoneal lymphatics as well as donor lymphatics accompanying the allograft. A peri-graft lymphocele is well-recognised morbidity following renal transplantation and can manifest in a broad spectrum of clinical presentations.
PATHOPHYSIOLOGY AND RISK FACTORS Surgery related risk factors
the donor and recipient operation. During donor kidney procurement, hilar lymphatics may be damaged either at the time of nephrectomy or during ‘back-table’ dissection. These damaged lymphatics continue to leak lymph after reperfusion and can contribute to lymphocele formation. If dissected lymphatics around iliac vessels are ligated or clipped, it would leak lymph.
the presence of the allograft and associated inflammatory processes increase lymph flow from the renal hilum as well as from the lymphatics around iliac vessels, resulting lymphocele formation due to lymph leakage
other factors surrounding the recipient and donor operation have also been recognized as potential risk factors for the incidence of lymphocele. Laparoscopic donor nephrectomy has been implicated with a higher incidence of lymphocele compared to open nephrectomy. Saidi et al. ] reported a significantly higher incidence of lymphocele with laparoscopic live donor nephrectomy compared to deceased donor transplants.
the ipsilateral placement of the kidney and implantation to the common iliac vessels compared to contralateral iliac fossa placement and implantation to external iliac vessels was associated with a lower incidence of lymphocele (2.1% vs. 8.5%). The authors postulated that there is higher lymphatic disruption associated with dissection around the external iliac compared to common iliac vessels.
Non-surgical risk factors
Adult polycystic kidney disease in the recipient has also been described as a potential risk factor . The possible explanation has been the external pressure on the inferior vena cava by the polycystic kidney resulting in impaired lymphatic drainage from the allograft and iliac region. Obesity in the donor (BMI>30) has also been described as an independent risk factor for the occurrence of lymphocele
higher incidence of lymphocele with the use of sirolimus, mycophenolate and prednisolone combination. Furthermore, Langer also demonstrated that the use of sirolimus was an independent risk factor for lymphocele formation. However, a subsequent study by Tondolo et al.failed to show any correlation based on different immunosuppressive agents including sirolimus.
significantly higher incidence of lymphocele with the use of low molecular weight heparin after transplantation. The authors postulated that the increased anticoagulant effect impaired sealing of damaged lymphatics resulting in higher incidence of lymphocele.
the acute rejection of the graft as an independent risk factor for the incidence of lymphocele. Veeramani et al. also demonstrated that patients with symptomatic lymphoceles had a significantly higher incidence of acute rejection compared to those who had no lymphoceles (51% vs. 20%). The intense inflammatory process during an episode of acute rejection is involved with increased lymphangiogenesis and lymph flow, possibly explaining its association with lymphocele.
CLINICAL PRESENTATION
The vast majority of lymphoceles are asymptomatic and are detected as an incidental finding on imaging. Depending on the size, extent and location in relation to the allograft, lymphoceles may exert pressure effects causing symptomatic presentation
Large lymphoceles may cause abdominal discomfort, pain, urgency (due to bladder compression) and backache (sacral nerve compression). Association with wound dehiscence can lead to sepsis or lympho-cutaneous fistula. The latter presentation requires careful assessment to differentiate from urinary leakage and needs prompt intervention to prevent septic complications.
DIAGNOSIS The primary modality in diagnosis is imaging. USS can determine the collection as well as its dimensions, location in relation to the graft and possible effects on the graft vessels and ureter . USS guided aspiration, and biochemical analysis of contained fluid allows differentiation from urinary leak and urinoma. The biochemical analysis should be done for creatinine, electrolytes, protein content, gram stain and culture.
difference in the creatine kinase (CK) levels of the fluid based on its source, with recipient origin lymph demonstrating higher levels of CK. However, the clinical utility of this analysis from a management perspective remains unproven.
TREATMENT
The vast majority of asymptomatic lymphoceles are selflimiting and do not require specific treatment. Once they are detected, further testing is done to establish any pressure effects on the vasculature or ureter. In the absence of any demonstrable pressure effects or evidence of infection, such lymphoceles can be safely left alone with periodic imaging surveillance. Notably, small lymphoceles located cephalad to the graft, away from the vasculature and ureter are unlikely to cause pressure effects and rarely need intervention. The decision to intervene depends on definitive pressure effects causing symptoms, graft dysfunction, evidence of sepsis or fistula formation. The reported incidence of lymphoceles requiring definitive intervention varies between 0.04-14.6%
Intra-operative drain placement
The placement of retroperitoneal drains adjacent to the graft at the time of transplantation is a practice performed by many surgeons. These are usually removed once the drainage becomes negligible or before hospital discharge.
Percutaneous aspiration and sclerotherapy
Symptomatic lymphoceles can be aspirated under USS guidance and remain the safest mode of intervention where needed. It also allows for sampling of the collection to establish its true nature and rule out infection. Percutaneous aspiration can, at the best, is a diagnostic step that helps in differentiation from urinoma.
Laparoscopic fenestration
Large lymphoceles can be opened into the peritoneal cavity by making fenestrations in the lymphocele capsule. This allows for lymph to be internally drained to the peritoneal cavity whereby the peritoneal lymphatics would drain it into thoracic duct. In patients who are fit to undergo general anesthesia, this can be performed by laparoscopic fenestration.
Open surgery Open surgical drainage of lymphocele is required in the presence of infection (external drainage) or where laparoscopic fenestration is not possible (internal drainage to the peritoneum). In this era of laparoscopy, open drainage is only of historical importance.
CONCLUSION
Peri-graft lymphocele is fairly common morbidity following renal transplantation. However, the vast majority of these remains asymptomatic and is self-limiting. Nevertheless, close surveillance is required to rule out pressure effects on the graft and possible secondary infection. Multiple risk factors have been described which helps in identifying patients at a higher risk of lymphocele. Symptomatic or complicated lymphoceles require prompt intervention with minimal morbidity to the graft as well as the patient.
Abdullah Raoof
2 years ago
W9 j 3
Iii . Lymphocele after Renal Transplantation – A New Look at an Age-Old Problem!
Q1- Please summarise this article ?
ABSTRACT
Post-transplant lymphocele incidence is 0.6-34%.
Most of these cases are asymptomatic and are found incidentally on routine imaging of the allograft. Large volume lymphoceles and those in the graft hilum can produce pressure effects causing graft dysfunction. Local symptoms may develop if venous or lymphatic outflow of gonads or lower limb is affected. Symptomatic lymphoceles need definitive treatment.
INTRODUCTION
Definition:- A lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialized cover, usually occurring at a site of extensive surgical dissection. It is occur because of damage to host and donor lymphatics .
Is well- recognised complication it has variable presentation range asymptomatic to graft dysfunction, vascular compromise or sepsis. The peak incidence is at 6 weeks post- transplant but it could present as early as 1-2 weeks after transplant or months to years after transplantation.
PATHOPHYSIOLOGY AND RISK FACTORS
Surgery related risk factors:
1- Damage to hilar lymphatics .
2- If dissected lymphatics are ligated or clipped, it would leak lymph.
3- Diathermy use which does not close lymph vessels .
4- Laparoscopic donor nephrectomy. Saidi et al. reported a higher incidence of lymphocele with laparoscopic live donor nephrectomy compared to deceased donor transplants.
Non-surgical risk factors:
1) diabetes in the recipient.
2) Adult polycystic kidney disease.
3) Obesity in the donor (BMI>30).
4) sirolimus, mycophenolate and prednisolone combination or sirolimus it self .
5) rabbit anti- thymocyte globulin induction.
6) use of low molecular weight heparin after transplantation.
7) increased recipient age.
8) increased warm ischaemia time.
9) acute tubular necrosis .
10) delayed graft function .
11) prolonged pre-transplant dialysis .
12) and re- transplantation.
CLINICAL PRESENTATION:
The vast majority are asymptomatic and are detected on imaging.Pressure presentation Depend on the size, extent and location in relation to the allograft.
This may cause
1- renal artery or vein thrombosis.
2- Hydro-ureter or hydro- nephrosis.
3- Unilateral limb edema.
4- scrotal or vulval edema.
5- deep vein thrombosis of the iliac veins.
6- pain, and urgency.
7- Backache.
8- association with wound dehiscence can lead to sepsis or lympho-cutaneous fistula.
DIAGNOSIS:
The primary modality in diagnosis is imaging by abdominal ultrasound.
USS guided aspiration, and biochemical analysis of fluid Helps to differentiation from urinary leak and urinoma. Biochemical analysis should be done for creatinine , electrolytes, protein , gram stain and culture. USS appearance can also indicate the presence of infection within the collection.
TREATMENT:
MOST of asymptomatic lymphoceles are self- limiting and do not require specific treatment.
The decision to intervene depends on definitive pressure effects causing
a) symptoms,
b) graft dysfunction,
c) evidence of sepsis or fistula formation.
incidence of lymphoceles requiring intervention is between 0.04-14.6%.
1- Intra-operative drain placement:
The placement of retroperitoneal drains aroutine practice performed by many surgeons. 2- Percutaneous aspiration and sclerotherapy:
Symptomatic lymphoceles can be aspirated under USS guidance and it is the safest intervention. It help in sampling of the collection to establish its true nature and rule out infection. simple aspiration alone associated with a recurrence rate 59% , compared to 50% with percutaneous drain placement. 3- Laparoscopic fenestration:
Large lymphoceles can be opened into the peritoneal cavity by making fenestrations in the lymphocele capsule. But infection should be excluded before this action. 4- Open surgery:
Open surgical drainage of lymphocele is required in the presence of infection (external drainage) or where laparoscopic fenestration is not possible. In this era of laparoscopy, open drainage is rarely used. Lymphoceles located in relation to the lower pole of the graft or complex lymphoceles causing vascular compromise is best treated by open de-roofing.
Q2- What is the level of evidence provided by this article?
It is level 5.
Mu'taz Saleh
2 years ago
1-Please summarize this article : Introduction :
A Lymphocele is one of the most common surgical complication post renal transplantation which may present as early as 1-2 weeks or several months to years post transplantation with incidence ranging from 0.6% to 34%
lymphocele is an abnormal fluid collection around the transplanted kidney due to surgical and medical risk factors .
Risk factors :
Surgical risk factors
Damaging of hilar lymphatics during nephrectomy or ‘back-table’ dissection .
Inflammatory process associated with kidney transplantation increase lymph flow from the renal hilum resulting lymphocele .
Contra lateral iliac fossa placement of transplanted kidney and implantation to external iliac vessels
Non surgical risk factor
DM
APKD
Obesity BMI > 30
Sirolimus or ATG
Increased recipient age,
Increased warm ischaemia time
Acute tubular necrosis and delayed graft function ,
Prolonged pre-transplant dialysis
Re-transplantation
Clinical presentation:
The majority are asymptomatic. Symptoms may occur depending on the size , site and extent to the surrounding tissues.
Pressure effect on the hilar vessels may lead to impaired graft function or even venous or arterial thrombosis , pressure effect on ureter lead to hydro ureter and HN .
Pressure on the recipient iliac vein or compression of lymph drainage may lead to unilateral limb oedema, scrotal or vulval oedema and deep vein thrombosis of the iliac veins.
Large lymphoceles may cause abdominal discomfort, pain, urgency and backache (sacral nerve compression). Association with wound dehiscence can lead to sepsis or lympho-cutaneous fistula.
Diagnosis : The diagnosis is realized with imaging. The simplest method is the USS, determining the collection and its dimensions, location, relationship with the graft and compression effects on the vessels and ureter. Allows guided aspiration and biochemical analysis of contained fluid allows differentiation from urinary leak and urinoma.
Treatment : Most of the asymptomatic lymphoceles require no specific treatment but they need to be assessed and followed for any pressure effects on the vasculature or ureter. Avoidance is through placement of retroperitoneal drains adjacent to the graft at the time of transplantation. For symptomatic ones, treatment modalities include percutaneous aspiration, sclerotherapy and laparoscopic fenestration.
What is the level of evidence provided by this article?
Level V
Asmaa Khudhur
2 years ago
1-Please summarise this article:
A lymphocele can be defined as an abnormal collection of lymphatic fluid that lacks an epithelialized cover, usually occurring at a site of extensive surgical dissection.
Post-transplant lymphocele has a reported incidence of 0.6-34%.
Risk factors include both surgical and non-surgical factors:
Surgical factors include:
Donor and recipient related factors and include damage to the hilar lymphatics during Nephrectomy or during back-table dissection , presence of allograft and the inflammatory processes all increase the lymphatics leak.also laparoscopic donor Nephrectomy and complex arterial anatomy, also ipsilateral placement of the kidney and implantation to the common iliac vessels compared to contralateral iliac fossa placement and implantation to external iliac vessels was associated with a lower incidence of lymphocele.
Non-surgical risk factors:
Use of tacrolimus
the incidence of acute rejection
diabetes in the recipient were all associated with lymphocele formation .
Adult polycystic kidney disease in the recipient .
Obesity in the donor (BMI>30) .
higher incidence of lymphocele with the use of sirolimus, mycophenolate and prednisolone combination.
higher incidence of lymphocele with the use of low molecular weight heparin after transplantation.
increased recipient age.
increased warm ischaemia time .
acute tubular necrosis and delayed graft function .
prolonged pre-transplant dialysis and re- transplantation .
Clinical presentation:
The majority are asymptomatic. Symptoms may occur depending on the size , site and extent to the surrounding tissues.
Pressure effect on the hilar vessels may lead to impaired graft function or even venous or arterial thrombosis , pressure effect on ureter lead to hydro ureter and HN .
Pressure on the recipient iliac vein or compression of lymph drainage may lead to unilateral limb oedema, scrotal or vulval oedema and deep vein thrombosis of the iliac veins.
Large lymphoceles may cause abdominal discomfort, pain, urgency and backache (sacral nerve compression). Association with wound dehiscence can lead to sepsis or lympho-cutaneous fistula. Modality of diagnosis:
US
Biochemical analysis of drains fluid
CT scan .
TREATMENT:
Intra-operative drain placement
Percutaneous aspiration and sclerotherapy
Laparoscopic fenestration
Open surgery
2-What is the level of evidence provided by this article?
Narrative review level V
Wael Jebur
2 years ago
Lymphocele is a common complication after kidney transplantation, notwithstanding, majority are asymptomatic. Its prevalent in about 0.6-34% of allograft recipients. Symptomatic lymphocele reported in 5.2%.
Reported to occur as early as 1-2 weeks post-transplant and as late as years thereafter.
Risk factors are surgical and non-surgical.
Surgical risk factors are donor related and recipient related. Donor related factors:
During harvesting the kidney, renal hilum might be injured, or secondly while preparing the allograft.
Allograft with multiple renal arteries is increasingly prone to develop lymphocele.
Laparoscopic nephrectomy of life donors is linked to heightened incidence. Recipient related:
Extensive clipping or ligation of pelvic lymphatic around iliac vessels might re-leak. Lymphatic diathermy is non secure and associated with high recurrence of lymphatic leak.
presence of allograft with inflammation, infection or rejection is augmenting lymphatic leak.
Utilizing common iliac artery is safer for implementing the allograft then external iliac artery owing to complex anatomical field necessitating wide lymphatic dissection. Non-surgical causes:
Sirolimus based regimen is associated with increasing incidence. Similarly, induction with ATGr was reported.
Diabetes mellitus, obesity, prolonged dialysis duration pre transplantation, Tacrolimus, acute rejection, ATN and delayed graft function.
Its mor prevalent in APCKD recipients due to compression of IVC by huge size polycystic kidney.
Clinical presentation:
Majority is asymptomatic detected by screening US post transplantation.
When its sizeable lymphocele, pressure symptoms might supervene, such as hydroureter and hydronephrosis, pressure on deep veins causing DVT, lymphatic obstruction causing testicular or labial swelling. Opening of the wound with lymphatic fistula might be encountered, a condition that predispose to superadded infection. Diagnosis:
US study is essential in determining extent, location and potential consequences of lymphocele. As its illustrative of anechoic cystic lesion. increased opacity of the same cyst is indicative of potential complicating abscess.
aspiration and analysis of fluid simultaneously with serum is advocated in certain situation when diagnosis is in doubt.
CK was speculated to be elevated in Lymphocele fluid.
Management:
The key point indicative of necessity to commence management is pressure features, infection, allograft dysfunction and fistula.
Keeping extra-peritoneal drain is associated with lower incidence of lymphocele.
Usually, lymphocele of more than 140 ml is usually symptomatic. And more than 500 ml is unlikely to resolve with aspiration or sclerotherapy.
Fenestration of lymphocele to peritoneal cavity is the main strategy to mitigate lymphatic collection.
Open surgical drainage is indicated in infective lymphocele.
Lymphocele located near lower pole of allograft or causing vascular compromise is an indication for open surgery and de-roofing
-higher lymphatic disruption associated with dissection around the external iliac compared to common iliac vessels
NON-SURGICAL RISK FACTORS
– diabetes in the recipiente
– Adult polycystic kidney disease in the recipiente
– Obesity in the donor (BMI>30)
– increased recipient age;
– increased warm ischaemia time;
– acute tubular necrosis and delayed graft function
– prolonged pre-transplant dialysis
– retransplantation
The correlation between the incidence of lymphocele and the use of different immunosuppressive agents is controversial. Alguns estudos demonstrated a significantly higher incidence of lymphocele with the use of sirolimus, mycophenolate and prednisolone combination, ou ainda, o uso de sirolimus isolado, enquanto outros trabalhos não encontram relação.
The majority of lymphoceles are asymptomatic and are detected as an incidental finding on imaging. Depending on the size, extent and location in relation to the allograft, lymphoceles may exert pressure effects causing symptomatic presentation, for example : pressure on the recipient iliac vein or compression of lymph drainage may lead to unilateral limb oedema, scrotal or vulval oedema and deep vein thrombosis of the iliac veins. Large lymphoceles may cause abdominal discomfort, pain, urgency (due to bladder compression) and backache (sacral nerve compression).
The diagnosis is realized with imaging. The simplest method is the USS, determining the collection and its dimensions, location, relationship with the graft and compression effects on the vessels and ureter. Allows guided aspiration and biochemical analysis of contained fluid allows differentiation from urinary leak and urinoma.
The vast majority of asymptomatic lymphoceles are self-limiting and do not require specific treatment. Once they are detected, further testing is done to establish any pressure effects on the vasculature or ureter and the decision to intervene depends on definitive pressure effects causing symptoms, graft dysfunction, evidence of sepsis or fistula formation.
Possible interventions are:
– Intra-operative drain placement : there are controversial results regarding the benefit of retroperitoneal drains adjacent to the graft at the time of transplantation.
– Percutaneous aspiration and sclerotherapy: isolated aspiration may have a high recurrence rate, while drain placement may cause infection. The use of sclerosants appears as an alternative to reduce the risk of these unwanted events.
– Laparoscopic fenestration: trata-se da drenagem in peritoneal cavity. it has shown high rates of success with a minimal rate of recurrence and lower procedure-related morbidity, and reduced overall hospital stay compared to open surgical drainage
– Open surgery: necessary in presence of infection (external drainage) or where laparoscopic fenestration is not possible (internal drainage to the peritoneum)
What is the level of evidence provided by this article?
Level evidence is 05 because is a narrative reviews
Manal Malik
2 years ago
Lymphocele after Renal Transplantation – A New Look at an Age-Old Problemintroduction
Lymphocele is known cause of graft dysfunction and p==mortality.
Clinical presentation such as compression effect on the graft and subsequent graft dysfunction vascular insufficiency or sepsis.
Incidence of lymphocele is from 0.6 to 39%
It can occurs from 1-2 week post kidney transplant up to several months to years. Pathophysiology and risk factors: Surgery related risk factors for donor and recipient donor
Donor factors:
· Damage of lymphatics during nephrectomy.
· Clipped or ligated lymphatics and iliac vessels.
· Associated inflammatory process.
· Laparoscopic donor nephrectomy has a higher incidence of lymphocele.
· Multiple renal arteries in the donor carry a high risk of lymphocele
· Ipsilateral placement of kidney transplantation has a lower incidence of lymphocele Nonsurgical risk factors:
Ø Adult polycystic kidney disease in the recipient
Ø Obesity in the donor BMI>30 has an independent risk factor for the occurrence of lymphocele
Ø The correlation between the incidence of lymphocele and the use of different immunosuppression agents is controversial.
Ø Other risk factors for lymphocele in kidney transplantation recipient
1. Increase recipient age
2. Acute tubular necrosis
3. Delay graft function
4. Prolong pre-transplant dialysis
5. Re transplantation Clinical presentation:
Could be non indicated finding on imaging.
Compression symptoms include renal vein or artery thrombosis
Hydroureter
Unilateral limb oedema
Scrotal or valval oedema
Large lymphocele can cause abdominal discomfort, pain,and back pain Diagnosis:
Ultrasonography determine the collection as well as the location
U/S quidded aspiration and biochemical analysis of contained fluid to differentiate from urine leak and urinoma
Biochemical analysis should be done for electrolytes, protein content, gram stain, and culture and sometime take creatinine and electrolytes from urine sample
CT can differentiate lymphocele from haematoma Treatment:
Asymptomatic lymphocele is self limiting
Symptomatic lymphocele especially graft function, sepsis or fistula formation need surgical intervention
Remaining the drain in place individual choice Percutaneous aspiration and sclerotherapy:
Symptomatic lymphocele can be aspirate under U/S guidance
Some lymphocele needs percutaneous drain to minimize re accumulation
Lymphocele volume >140ml and septic and >500ml were unlikely to resolve with percutaneous aspiration sclerotherapy or drain placement needed. Laparoscopic fenestration:
Large lymphocele opened into peritoneal cavity by fenestration in to lymphocele capsules but first need to role out infection Open surgery:
If infected lymphocele so surgical damage is best option or laparoscopic fenestration is not possible. Conclusion:
Lymphocele usually a symptomatic and self-limiting
Patients been at risk due to multiple risk factors.
Symptomatic or complicated lymphocele required intervention
Laparoscopic fenestrations into the peritoneal cavity treatment option recurrent collection or large volume lymphocele.
level 5
rindhabibgmail-com
2 years ago
The lymphocele are usually asymptomatic identified incidentally on imaging until unless causing pressure effects on vessels, ureter etc, and they may compromise graft function with venous thrombosis, lymphatic obstruction, if not treated urgently. some times large enough to cause abdominal discomfort, pain, pressure effect on bladder and with frequency and urgency, sacral nerve compression and some time wound dehiscence. Its very common after ureteric leak around 2 to 34%. The risk factors hilar lymphatic damage, obesity >30, diabetic, use of sirolimus.
If asymptomatic and with pressure effect can wait and observe, if symptomatic then surgical approach.
level V
Hinda Hassan
2 years ago
1. Please summarise this article
Post-transplant lymphocele is an abnormal collection of lymphatic fluid adjacent to the graft with incidence of 0.6-34%.
RISK FACTORS:
1-Surgical risk factors: hilar lymphatics damage, increase lymph flow due to inflammatory processes, laparoscopic donor nephrectomy, donor kidneys with complex arterial anatomy , contralateral placement of the kidney and implantation to the external iliac vessels
2- Non-surgical risk factors: diabetes in the recipient, adult polycystic kidney disease in the recipient, obesity in the donor (BMI>30), use of sirolimus alone, use of sirolimus combined with mycophenolate and prednisolone, rabbit ATG induction, LMW heparin after transplantation, increased recipient age, increased warm ischaemia time, ATN and DGF, prolonged pre-transplant dialysis, retransplantation and acute rejection.
Symptoms and signs:
Mostly are asymptomatic discovered incidentally on routine imaging of the allograft. They may cause graft dysfunction, vascular compromise or sepsis. They increase the risk of acute rejection compared to those who had no lymphoceles. They might exert pressure on the hilar vessels and lead to impaired graft function, renal artery or vein thrombosis. lymphatic outflow obstruction of gonads or lower limb may lead to unilateral limb oedema, scrotal or vulval oedema and deep vein thrombosis of the iliac veins. . Pressure on the ureter may lead to hydroureter or hydronephrosis of the graft. Large lymphoceles may cause abdominal discomfort, pain, urgency and sacral nerve compression. They may end with wound dehiscence ending with sepsis or fistula.
DIAGNOSIS:
Ultrasound imaging is important in diagnosis and management through US guided aspiration. The aspirate biochemical analysis and serum analysis will differentiate it from urinary leak and urinoma (creatinine, electrolytes, protein, gram stain and culture). Presence of debris and complex echo pattern would signify infection within the collection.
TREATMENT:
Most of the asymptomatic lymphoceles require no specific treatment but they need to be assessed and followed for any pressure effects on the vasculature or ureter. Avoidance is through placement of retroperitoneal drains adjacent to the graft at the time of transplantation.
For symptomatic ones, treatment modalities include percutaneous aspiration, sclerotherapy and laparoscopic fenestration. 1. What is the level of evidence provided by this article? Level V
MICHAEL Farag
2 years ago
What is the level of evidence provided by this article?
Level V
INTRODUCTION
A lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialized cover, usually occurring at a site of extensive surgical dissection.
In renal transplantation, a lymphocele may occur adjacent to the graft, due to multiple
factors including damage to host retroperitoneal lymphatics as well as donor lymphatics accompanying the allograft. A peri-graft lymphocele is well-recognised morbidity following renal transplantation and can manifest in a broad spectrum of clinical presentations. This can range from indolent collections detected merely as incidental findings on or those that cause graft dysfunction, vascular compromise or sepsis.
The peak incidence of lymphoceles has been reported at 6 weeks post-transplant. However, it may occur as early as 1-2 weeks after transplant and may occur several months to years after transplantation
CLINICAL PRESENTATION
It depends on the site and the size
– asymptomatic and are detected as an incidental finding on imaging.
– Pressure on the hilar vessels can lead to impaired graft function and may even lead to
catastrophic renal artery or vein thrombosis in rare instances where it goes undetected.
– Pressure on the ureter may lead to hydroureter or hydronephrosis of the graft.
– Pressure on the recipient iliac vein or compression of lymph drainage may lead to unilateral limb oedema, scrotal or vulval oedema and deep vein thrombosis of the iliac veins.
– Large lymphoceles may cause abdominal discomfort, pain, urgency (due to bladder compression) and backache (sacral nerve compression). Association with wound dehiscence can lead to sepsis or lympho-cutaneous fistula.
DIAGNOSIS
USS and or CT abdomen can determine the collection as well as its dimensions, location in relation to the graft and possible effects on the graft vessels and ureter
TREATMENT
– The vast majority of asymptomatic lymphoceles are self-limiting and do not require specific treatment especially if no compression on the adjacent graft and its vasculature
– The placement of retroperitoneal drains adjacent to the graft, These are usually removed once the drainage becomes negligible or before hospital discharge.
– Percutaneous aspiration and sclerotherapy.
– Large lymphoceles can be opened into the peritoneal cavity by making fenestrations in the lymphocele capsule.
– Open surgical drainage of lymphocele is required in the presence of infection (external drainage) or where laparoscopic fenestration is not possible
Huda Saadeddin
2 years ago
A lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialized cover, usually occurring at a site of extensive surgical dissection.
Post-transplant lymphocele has a reported incidence of 0.6-34%.
The incidence of symptomatic lymphocele is much lower and has been reported at a mean of 5.2% (range 0.03- 26%)
The peak incidence of lymphoceles has been reported at 6 weeks post-transplant.
Peri-graft lymphocele is fairly common morbidity following renal transplantation. However, the vast majority of these remains asymptomatic and is self-limiting. Nevertheless, close surveillance is required to rule out pressure effects on the graft and possible secondary infection. Multiple risk factors have been described which helps in identifying patients at a higher risk of lymphocele. Symptomatic or complicated lymphoceles require prompt intervention with minimal morbidity to the graft as well as the patient. Small volume collections, only if there is clinical indication, may be treated with percutaneous techniques to allow resolution. Recurrent collections or large volume lymphoceles are best treated by laparoscopic fenestration into the peritoneal cavity. Open surgical de-roofing is of historical importance.
level 5
Last edited 2 years ago by Huda Saadeddin
Balaji Kirushnan
2 years ago
Lymphocele is a collection of the lymphatic fluid at the site of surgical dissection without an epithelial cover…In renal transplantation peri graft lymphocele has been associated with variable incidence of 3 to 25% in various studies…The variable incidence has been told due to screening USG being done only if patient are symptomatic…The actual incidence of symptomatic lymphocele has been only 5%. Lymphocele usually occur within 4 to 6 weeks after transplant but chronic asymptomatic lymphocele have been reported too….
Surgery related risk factors include many hypothesis related to cause lymphatic damage…During donor nephrectomy hilar lymphatics can get damaged during nephrectomy or during the bench dissection…Improper dissection of the iliac lymphatics have been implicated in causing lymphocele especially if they are clipped or ligated they can leak alter…Diathermy does not cauterize the lymphatics as they do for the blood vessels…Persistent Graft inflammation may cause lymph ooze from the hilum and may need to lymphocele…Laparoscopic donor nephrectomy has been implicated to cause higher damage to the lymphatics as compared to the open nephrectomy techniques.. Donor kidneys with more renal arteries are known to be associated with lymph damage…some studies say that the contralateral kidney placement and use of external iliac are associated with higher degree of lymph dissection…
Non surgical risk factors are diabetes, obesity in recipients, use of sirolimus and presence of graft inflammation in rejections are known to be associated with graft lymphocele….
The vast majority of them are asymptomatic and detected only on ultrasound. Symptomatic lymphocele are when they compress the neighboring structures causing HUN, renal vein thrombosis or kinking of the renal artery etc..It can even compress the ipsilateral common iliac vein and lead to DVT, scrotal edema or vulval edema…If the lymhocele is infected it can cause pain and tenderness of the graft site adjacent to it.. Large lymphocele cause subcutaneous compression and lead to lymphocutaneous fistula
Once confirmed by USG it has to be aspirated and send for analysis to rule of infection and to confirm its only lymph and not urine…The drain fluid creatinine and potassium will be same as plasma in lymphocele and it will be very high if it is a urinoma…We should make sure there are no infections before analyzing the permanent solution for the lymphocele as aspiration of the lymphocele is associated with highest rate of recurrence….
small asymptomatic lymphocele can be left as it is…The large symptomatic lymphocele are associated with compressive symptoms need to be drained…
USG guided aspiration is the standard procedure for sampling and at the same time many authors recommend instilling sclerosing agents and keeping a drain but these techniques are associated with higher infection and need repeated interventions….Laproscopic fenestration and opening the peritoneum into the abdominal cavity and allow the abdominal lymphatics to drain the lymphocele into the thoracic duct is an alternative…It is associated with high rates of success and less rates of recurrence…
this is a review article and hence level of evidence is 5
Amna Khalifa
2 years ago
Lymphocele after Renal Transplantation: A New Look at an Age-Old Problem!
Lymphocele is a collection of lymphatic fluid at a site with extensive dissection
It is associated with Injury to the recipient or donor lymphatics , as per site located some times it can carry great morbidity especially if it is located at the hilum of the graft.
Some were diagnosed incidentally while others presents with either graft dysfunction, vascular compression or sepsis.
Lymphocele incidence ranges from 0.3-34 % . however this is only it is discovered by imaging techniques. However it range from 0.03- 26% if it is symptomatic.
It can be collected in the couple of weeks post transplant however it reach the peak by the 6th weeks post transplant. PATHOPHYSIOLOGY AND RISK FACTORS Surgery related risk factors
1. During Donor kidney procurement, hilar lymphatics may be damaged either during nephrectomy or back table dissection.
2. Presence of inflammatory process around the allograft increase the lymphatic drainage.
3. Laparoscopic donor nephrectomy increases the risk
4. Donor kidney with complex arterial anatomy carries a higher risk
5. contralateral placement of the kidney non surgical risk factors
1. use of tacrolimus
2. acute rejection
3. diabetes
4. adult PKD
5. obesity in the donor
6. combination of sirolimus/MMF and prednisolone
7. induction with rabbit ATG
8. LMWH
9. Increased recipient age
10. Increase warm ischemia time
11. Acute tubular necrosis
12. Delayed graft function
13. Prolonged pre transplant dialysis
14. Re transplantation.
Clinical presentation
1. Asymptomatic: majority
2. Other symptomatic depending on size, extent and location in relation to allograft
· Pressure effect leading to hydroureter /hydronephrosis of the graft.
· Impaired graft function
· Renal artery /vein thrombosis
· Unilateral limb edema/scrotal/valval edema
· DVT iliac vessels
· Abdominal discomfort, pain
· Urgency
· Backache
· Sepsis or lympho-cutaneous fistula Diagnosis
Ultrasound scan to determine a collection
Uss guided aspiration and biochemical analysis to differentiate b/w urinary leak and urinoma
Analysis for : creatinine, electrolytes, protein content ,gram stain, culture
Comparing with simultaneous same from serum and urine for creatinine and electrolytes.
Treatment
Asymptomatic, usually small, can be left for reabsorption
Large or causing pressure effect/graft dysfunction/evidence of sepsis will requires intervention.
· Intraoperative drain placement
· Percutaneous aspiration with sclerotherapy.
· Laparoscopic fenestration.
. Open surgery
level of evidence 5
Tahani Ashmaig
2 years ago
Lymphocele after Renal Transplantation: A New Look at an Age-Ol problem
_____________________
Summary INTRODUCTION ▪︎ A lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialized cover, usually occurring at a site of extensive surgical dissection. ▪︎The lymphocele in renal transplantation can ocurr due to damage in host retroperitoneal lymphatics as well as donor lymphatics accompanying the allograft. ▪︎Clinical presentations of peri-graft lymphocele: range from indolent collections detected merely as incidental findings on or those that cause graft dysfunction, vascular compromise or sepsis. ◇ Risk factors of lymphocele according to different studies: 1. Damage to hilar lymphatics either at the time of nephrectomy or during ‘back-table’ dissection. 2. If dissected lymphatics around iliac vessels are ligated or clipped, it would leak lymph. 3. The presence of the allograft and associated inflammatory processes result in lymph leakage. 4. Laparoscopic donor nephrectomy. 5. Donor kidneys with complex arterial anatomy 6. Ipsilateral placement of the kidney & implantation to the common iliac vessels compared to contralateral iliac fossa placement & implantation to external iliac vessels was associated with a lower incidence of lymphocele (2.1% vs. 8.5%). 7. Maximum disruption of lymphatics. 8. Use of tacrolimus, 9. Adult polycystic kidney disease in the recipient 10. Obesity in the donor (BMI>30) 11. Immunosuppressive agents ( sirolimus, MMF and prednisolone combination. Sirolimus alone and ATG in induction. 12. LMW heparin after transplantation. 13. Increased recipient age 14. Increased warm ischaemia time 15. ATN and delayed graft function. 16. Prolonged pre-transplant dialysis. 17. Retransplantation. 18. acute rejection of the graft. CLINICAL PRESENTATION ▪︎Asymptomatic or may exert pressure effects causing symptomatic presentation. ▪︎Impaired graft function, catastrophic renal artery or vein thrombosis, hydro ureter or hydronephrosis of the graft, unilateral limb oedema, scrotal or vulval oedema and DVT of the iliac veins. ▪︎Large lymphoceles may cause abdominal discomfort, pain, urgency and backache (sacral nerve compression). ▪︎When associated with wound dehiscence can lead to sepsis or lympho-cutaneous fistula. DIAGNOSIS 1. USS can determine the collection as well as its dimensions, location in relation to the graft and possible effects on the graft vessels and ureter and the possible presence of infection. 2. USS guided aspiration, and analysis (creatinine, electrolytes, protein content, gram stain and culture) of contained fluid allows differentiation from urinary leak and urinoma. 3. CT can assist in differentiating innocuous lymphoceles from infected ones and other collections such as hematomas. 4. CK levels of the fluid to evaluate the origin of the lymph; donor or recipient (recipient origin demonstrating higher levels of CK). TREATMENT ▪︎In the absence of any demonstrable pressure effects or evidence of infection, such lymphoceles can be safely left alone with periodic imaging surveillance. ▪︎The decision to intervene depends on definitive pressure effects causing symptoms, graft dysfunction, evidence of sepsis or fistula formation. ▪︎Percutaneous aspiration and sclerotherapy ▪︎ Symptomatic ones can be aspirated under USS guidance and it can allow for sampling of the collection to establish its true nature and rule out infection. However, lymphocele would not be treated just by aspiration. ▪︎Some clinicians recommend: 1. Placement of a percutaneous drain to minimise reaccumulation 2. Sclerotherapy to sclerose open lymphatics. ▪︎Laparoscopic fenestration ▪︎ Large lymphoceles can be opened into the peritoneal cavity by making fenestrations in the lymphocele capsule. Open surgery: Is indicated when 1.There is infection or where laparoscopic fenestration is not possible. 2. The lymphoceles located in relation to the lower pole of the graft 3. There is complex lymphoceles causing vascular . However, open drainage carries a significantly higher risk of ureteric damage. CONCLUSION ▪︎ Peri-graft lymphocele is fairly common in renal transplant recipient. However, the vast majority of these remains asymptomatic and is self-limiting. ▪︎Close surveillance is required to rule out pressure effects and possible secondary infection. ▪︎Symptomatic or complicated lymphoceles require prompt intervention. ▪︎Small lymphoceles, only if there is clinical indication, may be treated with percutaneous techniques to allow resolution. ▪︎Recurrent collections or large volume lymphoceles are best treated by laparoscopic fenestration into the peritoneal cavity.
♧ Level of evidence: V
Theepa Mariamutu
2 years ago
Lymphocele
abnormal collection of lymphatic fluid that lacks an epithelialized cover
usually occurring at the site of extensive surgical dissection.
Post-transplant- may occur adjacent to the graft that may cause symptoms depending on the symptoms.
occur due to damage of recipient retroperitoneal lymphatics or donor lymphatics accompanying the allograft.
incidence is between 0.6%-34%.
incidence of symptomatic lymphoceles is much lower with a mean reported incidence of 5.2%
Risk Factors:
Surgical Risk factors:
More common than non-surgical risk factors
Donor kidney procurement – damage to the hilarity lymphatics which continue to leak lymph after reperfusion and can contribute to lymphocele formation.
dissected lymphatics around the iliac vessels are ligated or clipped, it would leak lymph.
Laparoscopic donor nephrectomy also has been known to increase the incidence
Sansalone et al – ipsilateral placement of the kidney and implantation to the common iliac vessels compared to contralateral iliac fossa placement and implantation to external iliac vessels was associated with a lower incidence of lymphocele.
Non-Surgical Risk Factors:
use of tacrolimus
diabetes
acute rejection
multivariate analysis – only diabetes in the recipient proved to be an independent risk factor
ADPKD in the recipient has also been postulated to be a risk factor.
Clinical Presentation:
Most of the lymphoceles are asymptomatic. Depending on the size and location in relation to the graft, lymphoceles may exert pressure effects.
Signs and symptoms include:
Graft dysfunction
Renal artery or vein thrombosis
Hydroureter or hydronephrosis
Abdominal discomfort
Abdominal pain
Backache
Wound dehiscence
Diagnosis:
USG is the gold standard for diagnosing lymphoceles as it can be used both as a diagnostic and diagnostic modality.
USS guided aspiration of the contents can help to differentiate from a urinary leak and urinoma.
Treatment:
asymptomatic and self limiting -do not require treatment.
In the absence of any pressure effects on USS, such lymphoceles can be monitored with serial USG
large and causing pressure symptoms, graft dysfunction, sepsis or fistula formation- require treatment.
Intra-operative drain placement: It has not been shown to conclusively reduce the incidence of lymphocele formation
Percutaneous aspiration and sclerotherapy: Some clinicians recommend placement of a drain to minimize re-accumulation but there is a risk of infection
Laparoscopic fenestration: large lymphoceles can be opened into the peritoneal cavity by making fenestrations in the lymphocele capsule. This allows for lymph to be internally drained into the peritoneal cavity. The presence of infection of the lymphocele needs to be carefully excluded before this procedure is carried out as it can lead to peritonitis
Open surgery This is carried out in the presence of infection where laparoscopic fenestration is not feasible. Open drainage carries a significantly higher risk of ureteric damage.
The level of evidence is V
Marius Badal
2 years ago
Summary:
Introduction
Lymphocele is a post-transplant complication that occurs during the first 6 weeks and some may happen even earlier than 1-2 weeks. It is an abnormal collection of lymphatic fluid due to the seal of perivascular lymphatic channels incised during operation. Its incidence is about 0.6-34% and its mean incidence peak is about 5.2%, 6 weeks post-transplantation.
The risk factors that may contribute:
1) During surgery, the donor kidney, and hilar lymphatics may be damaged probably during the time of nephrectomy or maybe during the dissection.
2) The cause of the leak is if the lymphatic around the iliac vessel were ligated or clipped.
3) Regarding open nephrectomy and laparoscopic surgery, laparoscopy surgery has a higher incidence of lymphocele than open surgery.
4) Depending on the complexity of the arterial anatomy of the kidney.
5) Other risk factors not surgical are:
a) diabetic patients.
b) Obesity
c) ADPKD
d) Recipient’s age
e) ATN
f) Delayed graft function
g) Depending on the ischemic warm time
The clinical presentation:
It can be asymptomatic that is dependent on the size of the lymphocele. It can be small or large volumes. The small lymphocele may be asymptomatic but the backflow pressure can cause impaired graft function, can cause hydronephrosis, scrotal or vulval edema, deep vein thrombosis, etc.
The large volume can cause pain, abdominal pain, lumbar pain urinary urgency, etc. There can be signs and symptoms of infection and wound dehiscence.
Diagnosis:
The collections are based on the:
1) Ultrasound to detect
2) Fluid can be removed via ultrasound-guided and test for culture, creatinine, potassium, etc.
3) CT scan
Treatment:
A) Asymptomatic lymphoceles, sometimes small volumes, may not require intervention or specific treatment. It is left alone and monitored for signs of infection.
B) Large-volume ones can make percutaneous aspiration and sclerotherapy can be done. If the infection is present treatment must be given.
C) Re-intervention surgically can be done.
D) Laparoscopic fenestration
So in conclusion, lymphocele is a surgical complication of transplantation that depending on the volume may be treated conservatively or surgically.
The article’s level of evidence is level 5
amiri elaf
2 years ago
# Please summarise this article
#The aim of this review:
To recognize the risk factors for lymphocele formation along with different management options and their outcomes.
# INTRODUCTION:
* A lymphocele is an abnormal accumulation of lymphatic fluid that lacks an epithelialized cover, usually occurring at a site where there is a massive surgical dissection.
*In renal transplantation, it is occur beside the graft, as a result of many factors including damage to recipient retroperitoneal lymphatics and donor lymphatics accompanying the allograft.
*Post transplant (PT) lymphocele rate shows a large variation ranging from 0.6% to 34%, and the peak incidence is a 6 weeks PT, but it can occur as early as 1-2 weeks and may occur several months to years PT. # Pathophysiology and risk factors: # Surgery related risk factors:
*When the hilar lymphatics damaged either at the time of nephrectomy or during ‘back-table’ dissection.
*If dissected lymphatics around iliac vessels are ligated or clipped, it would leak lymph.
*The presence of the allograft and associated inflammatory processes increase lymph flow from the renal hilum as well as from the lymphatics around iliac vessels, resulting in lymphocele formation.
* Laparoscopic donor nephrectomy has been implicated with a higher incidence of lymphocele compared to open nephrectomy.
*Complex arterial anatomy carried a higher risk of lymphocele compared to grafts with single renal artery.
*Ipsilateral placement of the kidney and implantation to the common iliac vessels compared to contralateral iliac fossa placement and implantation to external iliac vessels was associated with a lower incidence of lymphocele.
#Non-surgical risk factors
* Use of tacrolimus
*The incidence of acute rejection
* Diabetes in the recipient
*Adult polycystic kidney disease in the recipient
* Obesity in the donor (BMI>30)
*Use of sirolimus, mycophenolate and prednisolone combination.
*Use of rabbit anti-thymocyte globulin induction.
*Use of low molecular weight heparin after transplantation.
*Increased recipient age
*Increased warm ischaemia time
*Acute tubular necrosis and delayed graft function
*Prolonged pre-transplant dialysis
*Re-transplantation
#Clinical presentation
*The majority are asymptomatic
*Pressure on the hilar vessels can lead to:
Impaired graft function
Renal artery or vein thrombosis
It may goes undetected.
* Pressure on the ureter may lead to hydroureter or hydronephrosis of the graft.
* Pressure on the iliac vein or lymph drainage may lead to:
Unilateral limb oedema
Scrotal or vulval oedema
Deep vein thrombosis of the iliac veins.
*Large lymphoceles may cause abdominal discomfort, pain, urgency and backache.
*Sepsis, Lympho-cutaneous fistula and septic complications.
# Diagnosis
* USS (detect the collection, dimensions, relation to the graft, effects on the graft vessels and ureter).
* USS guided aspiration, and biochemical analysis of contained fluid (differentiate between the urinary leak and urinoma).
*Computerised tomography( differentiate lymphoceles from infected ones and other collections such as hematomas).
* Pacovsky et al. described higher levels of CK.
# Treatment
*The majority of asymptomatic are self-limiting and do not require specific treatment.
* In the absence of any demonstrable pressure effects or evidence of infection, it can be safely left alone with periodic imaging surveillance.
*The decision to intervene depends on definitive pressure effects causing symptoms, graft dysfunction, evidence of sepsis or fistula formation.
# Intra-operative drain placement
*The placement of retroperitoneal drains adjacent to the graft at the time of transplantation is a practice performed by many surgeons.
*These are usually removed once the drainage becomes negligible or before hospital discharge.
*Some studies have shown that drains placed intra-operatively decrease the incidence of lymphocele.
*It is remains an individual choice of the surgeon based on individual practice and patient characteristics.
# Percutaneous aspiration and sclerotherapy
*Symptomatic lymphoceles can be aspirated under USS guidance, it allows for sampling of the collection to establish its true nature and rule out infection.
* Percutaneous aspiration can, at the best, is a diagnostic step that helps in differentiation from urinoma.
*Some clinicians recommend placement of a percutaneous drain to minimise re-accumulation, but external drainage always get infected.
*The performing percutaneous drainage followed by sclerotherapy to sclerose open lymphatics with sclerosing agents have been described in various studies with varying degrees of success. These include; povidone iodine, fibrin glue, 95% ethanol, fibrinogen, sodium tetradecyl sulphate and tetracycline.
*The sclerosing agent has been instilled and kept in situ for varying periods ranging from 5 min to 24 h.
*There is a risk of introducing infection and direct graft injury and graft loss as a result of sclerosant installation.
# Laparoscopic fenestration
*Large lymphoceles can be opened into the peritoneal cavity by making fenestrations in the lymphocele capsule.
* Laparoscopic fenestration has shown high rates of success with a minimal rate of recurrence (4-8%).
# Open surgery
*Open surgical drainage of lymphocele is required in the presence of infection or where laparoscopic fenestration is not possible.
*Open drainage carries a significantly higher risk of ureteric damage and needs to be performed with the utmost care in order to minimize additional morbidity.
*The reported recurrence rate following open surgical drainage to the peritoneal cavity is 16% .
# What is the level of evidence provided by this article?
Level 5
Assafi Mohammed
2 years ago
Summary of the article “Lymphocele after Renal Transplantation – A New Look at an Age-Old Problem!” A lymphocele: is a lymphatic fluid collection without epithelial outline, and the reported incidence ranging from 0.6% to 34% post-transplant. The peak incidence of lymphoceles has been reported at 6 weeks post-transplant. However, it may occur as early as 1-2 weeks after transplant and may occur several months to years after transplantation. Causes and pathophysiology of lymphocele: A. Surgical risk factors: 1. Damage to host retroperitoneal lymphatics as well as donor lymphatics. 2. Donor kidneys with complex arterial anatomy carried a higher risk of lymphocele (12.5%). 3. Theipsilateral placement of the kidney and implantation to the common iliac vessels compared to contralateral iliac fossa placement and implantation to external iliac vessels was associated with a lower incidence of lymphocele. 4. Inflammatory processes increase lymph flow from the renal hilum as well as from the lymphatics around iliac vessels, resulting lymphocele formation due to lymph leakage. B. Non-surgical risk factors 1. Goel et al., and many authors have independently described the acute rejection of the graft as an independent risk factor for the incidence of lymphocele. 2. Diabetes in the recipient proved to be an independent risk factor. 3. Adult polycystic kidney disease in the recipient has also been described as a potential risk factor. 4. Obesity in the donor (BMI>30) has also been described as an independent risk factor for the occurrence of lymphocele. 5. The correlation between the incidence of lymphocele and the use of different immunosuppressive agents is controversial;
· Goel et al. demonstrated a significantly higher incidence of lymphocele with the use of sirolimus, mycophenolate and prednisolone combination.
· Langer demonstrated that the use of sirolimus was an independent risk factor for lymphocele formation.
· Tondolo et al. failed to show any correlation based on different immunosuppressive agents including sirolimus.
· Benavides described the higher incidence of lymphocele with the use of rATG induction.
· Lundin et al. demonstrated a significantly higher incidence of lymphocele with the use of low molecular weight heparin after transplantation.
6. Other risk factors implicated with lymphoceles in different studies include:
· Increased recipient age.
· Increased warm ischaemia time.
· Acute tubular necrosis and delayed graft function.
· Prolonged pre-transplant dialysis.
· Re-transplantation. Presentations of lymphocele: A. Asymptomatic, as incidental finding. B. Symptomatic:
1. Causing cause graft dysfunction
2. Pressure effect
3. Sepsis; Association with wound dehiscence can lead to sepsis or lympho-cutaneous fistula. It requires careful assessment to differentiate from urinary leakage.
Diagnosis of lymphocele: 1. USS can determine the collection as well as its dimensions, location in relation to the graft and possible effects on the graft vessels and ureter. 2. USS guided aspiration, and biochemical analysis of contained fluid allows differentiation from urinary leak and urinoma.
· The biochemical analysis should be done for creatinine, electrolytes, protein content, gram stain and culture.
· Higher level of creatine kinase (CK) of the fluid (the clinical utility of this analysis from a management perspective remains unproven).
· Comparison with simultaneous samples taken from serum and urine for creatinine and electrolytes often become invaluable in differentiating from urinoma.
Treatment
1. Asymptomatic lymphoceles are mostly self- limiting. Small and asymptomatic lymphocele can be safely left alone, if:
· No pressure effects(small lymphoceles located cephalad to the graft, away from the vasculature and ureter).
· No evidence of infection.
2. Intra-operative drain placement: Some studies have shown that drains placed intra- operatively decrease the incidence of lymphocele. 3. Percutaneous aspiration and sclerotherapy
· Aspiration under USS guidance; can be diagnostic and therapeutic.
· percutaneous drainage followed by sclerotherapy; but the chief drawbacks of repeated installation of sclerosants are the risk of introducing infection and graft loss(it is worthwhile that external drainage or sclersing therapy are not correct options).
4. Laparoscopic fenestration: this allows for lymph to be internally drained to the peritoneal cavity whereby the peritoneal lymphatics would drain it into thoracic duct. It’s associated with high rates of success with a minimal rate of recurrence(4-8%). Precautions for this intervention are:
· Patient is fit to undergo general anesthesia.
· No evidence of infection.
· No peritoneal adhesion.
· Technically reachable lymphocele and no adjacent abdominal viscus or vasculature.
· Lymphocele’s capsule shouldn’t be thick and impenetrable. 5. Open surgery; recurrence rate is 16% and ureteric injury is a high risk.
Open surgical drainage of lymphocele is required in the followings:
· The presence of infection.
· Laparoscopic fenestration is not possible.
· Complex lymphoceles causing vascular compromise.
· Lymphoceles located in relation to the lower pole of the graft.
What is the level of evidence provided by this article?
This is a narrative review article.
Level of evidence grade 5.
Mohamed Saad
2 years ago
Lymphocele after Renal Transplantation: A New Look at an Age-Old Problem! INTRODUCTION.
Lymphocele is lymph collection pre-graft after transplantation with peak incidence at 6 weeks post ktx, mainly due to seal of perivascular lymphatic channels incised during operation. RISK FACTORS. Surgical factors: –During nephrectomy lead to dissection of lymphatics.
– Associated inflammatory processes.
– Laparoscopic donor nephrectomy more than open.
– kidneys with complex arterial anatomy. Non-surgical risk factors.
– Use of tacrolimus & Sirolimus, the incidence of acute rejection and diabetes
-ADPKD, Obesity, association with drugs still debatable. CLINICAL PRESENTATION.
Asymptomatic mainly and are detected as an incidental finding on imaging, manifestation depending on the size, extent and location in relation to the allograft, lymphoceles.
– Pressure on the hilar vessels can lead to impaired graft function
– Pressure on the ureter may lead to hydro ureter or hydronephrosis.
– Unilateral limb oedema, scrotal or vulval oedema and deep vein thrombosis of the iliac veins.
– Large lymphoceles may cause abdominal discomfort, pain, urgency (due to bladder compression), backache (sacral nerve compression) and wound dehiscence.
-Lastly may lead to sepsis. DIAGNOSIS. –Detect collection by USG.
-Aspiration guided by USG and biochemical analysis of contained fluid (creatinine, electrolytes, protein content, gram stain and culture). TREATMENT.
–Conservative treatment with serial imaging is the rule for small lymphocele without compression.
– Percutaneous aspiration and sclerotherapy.
Placement of a percutaneous drain allows for continuous drainage as well as repeated instilling of sclerosants but sometimes is associated with infection. Laparoscopic fenestration.
To open into the peritoneal cavity by making fenestrations in the lymphocele capsule but first ,infection should be excluded. Open surgery.
With infected lymphocele with high risk of ureteric damage. CONCLUSION.
Lymphocele is surgical complication post ktx, mainly treated by conservative management , large one with pressure manifestation is treated by laparoscopic fenestration with good result.
Level of evidence :V
Mohammed Sobair
2 years ago
Please summarise this article
A lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialized
cover, usually occurring at a site of extensive surgical dissection.
Incidence ranging:
0.6% to 34%.
The incidence of symptomatic lymphocele is much lower and has been reported at a
mean of 5.2% the peak incidence of lymphoceles at 6 weeks post-transplant.
PATHOPHYSIOLOGY AND RISK FACTORS:
Surgical or medical risk factors:
The surgical risk factors involving the donor and recipient operation.
Donor kidney, hilar lymphatics may be damaged either at the time of nephrectomy or
during dissection.
If the lymphatics around iliac vessels were ligated or clipped, it would leak lymph.
Laparoscopic donor nephrectomy has been implicated with a higher incidence of
lymphocele compared to open nephrectomy.
Complex arterial anatomy.
Ipsilateral placement of the kidney and implantation to the common iliac vessels
compared to contralateral iliac fossa placement and implantation to external iliac vessels
was associated with a lower incidence of lymphocele.
Non-surgical risk factors:
Drug implication is controversial, Use of tacrolimus, the incidence of acute rejection and
diabetes in the recipient were all found to be significant in univariate analysis.
Adult polycystic kidney.
Obesity.
Increased recipient age.
Increased warm ischemia time.
Acute tubular necrosis.
Delayed graft function.
Prolonged pre-transplant dialysis.
Retransplantation.
CLINICAL PRESENTATION:
Asymptomatic:
Detected as an incidental finding on imaging.
Symptomatic presentation:
Pressure effect:
On the hilar vessels can lead to impaired graft function.
Renal artery or vein thrombosis.
Pressure on the ureter:
Hydroureter or hydronephrosis of the graft.
Pressure on the recipient iliac vein or compression of lymph drainage may lead to
unilateral limb edema, scrotal or vulval edema and deep vein thrombosis of the iliac vein.
Bladder compression, urgency.
Pressure on abdomen, cause abdominal discomfort.
Sacral nerve compression), pain, and backache.
Pressure on wound, Association with wound dehiscence can lead to sepsis or lympho-
cutaneous fistula.
DIAGNOSIS:
USS for diagnosis, Complex echo pattern with internal debris within the collection is
more indicative of complicated infected lymphocele.
CT scan.
USS guided aspiration, and biochemical analysis of contained fluid allows differentiation
from urinary leak and urinoma.
The biochemical analysis, for creatinine, electrolytes, protein content, gram stain and
culture.
Comparison with simultaneous samples taken from serum and urine for creatinine and
electrolytes.
TREATMENT:
Asymptomatic lymphoceles are self-limiting and do not require specific treatment.
In the absence of any demonstrable pressure effects or evidence of infection, such
lymphoceles can be safely left alone with periodic imaging surveillance.
Intraoperatively drain decrease the incidence of lymphocele.
Percutaneous aspiration and sclerotherapy:
Symptomatic lymphoceles can be aspirated under USS guidance.
Laparoscopic fenestration:
Has shown high rates of success with a minimal rate of recurrence (4-8%).
Open surgery:
Surgical drainage of lymphocele is required in the presence of infection (external
drainage) or where laparoscopic fenestration is not possible.
CONCLUSION:
Peri-graft lymphocele is common. However, the vast majority of these remains
asymptomatic and is self-limiting.
Close surveillance is required to rule out pressure effects on the graft and possible
secondary infection.
What is the level of evidence provided by this article?
Level of evidence V.
Yashu Saini
2 years ago
INTRODUCTION
This review evaluates the risk factors, management and outcomes of lymphocele formation post kidney transplantation. Lymphocele is a collection of lymphatic fluid which occurs at the extensive surgical dissection site. It lacks epithelialized cover.
Post renal transplant, lymphocele usually occurs adjacent to the graft mainly due to:
damage to the host retero-peritoneal lymphatics
damage to donor lymphatics accompanying the graft
Clinical presentation
Asymptomatic collection detected incidentally
Graft dysfunction
Vascular compromise
Sepsis
Mean incidence is 5.2%
Time to peak incidence is 6 weeks post transplant.
PATHOPHYSIOLOGY AND RISK FACTORS Surgical risk factors
Damage to hilar lymphatics at the time of donor kidney procurement
Ligation or clipping of dissected lymphatics
Increased lymph flow due to associated inflammatory processes in presence of allograft.
Laparoscopic donor nephrectomy
Non-surgical risk factors
Diabetes in recipient
Adult polycystic kidney disease
Obesity (BMI>30)
CLINICAL PRESENTATION
Pressure on hilar vessals – Impaired graft function / renal artery or vein thrombosis
Pressure on Ureter – Hydronephrosis or hydroureter
USG guided aspiration for biochemical analysis of fluid (creatinine, protein, gram stain and culture)
TREATMENT
Intra-operative drain placement
Percutaneous aspiration and sclerotherapy
laproscopic fenestration
Open surgery
CONCLUSION
Peri-graft lymphocele is fairly common
Vast majority of these remain asymptomatic and self -limiting
Symptomatic or complicated lymphoceles require prompt intervention
Recurrent lympohoceles or large lymphoceles are best treated with laproscopic fenestration into peritoneal cavity
Hussein Bagha baghahussein@yahoo.com
2 years ago
The article discusses the risk factors, pathogenesis and treatment options of lymphocele post renal transplant
Introduction:
A lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialized cover, usually occurring at the site of extensive surgical dissection. Post-transplant, a lymphocele may occur adjacent to the graft that may cause symptoms depending on the symptoms. It can occur due to damage of recipient retroperitoneal lymphatics or donor lymphatics accompanying the allograft. The reported incidence of lymphocele is variable as majority are asymptomatic and self resolving and will not be diagnosed. The reported incidence is between 0.6%-34%. The incidence of symptomatic lymphoceles is much lower with a mean reported incidence of 5.2%
Pathophysiology and Risk Factors:
The etiology of lymphocytes may be categorized broadly into medical and surgical factors. Surgical Risk factors:
More common than non-surgical risk factors
Donor kidney procurement can lead to damage to the hilarity lymphatics which continue to leak lymph after reperfusion and can contribute to lymphocele formation.
If dissected lymphatics around the iliac vessels are ligated or clipped, it would leak lymph.
Laparoscopic donor nephrectomy also has been known to increase the incidence of lymphoceles
Sansalone et al demonstrated that ipsilateral placement of the kidney and implantation to the common iliac vessels compared to contralateral iliac fossa placement and implantation to external iliac vessels was associated with a lower incidence of lymphocele. Non-Surgical Risk Factors:
In one study, use of tacrolimus, diabetes and acute rejection were found to increase the incidence of lymphoceles. However, during multivariate analysis, only diabetes in the recipient proved to be an independent risk factor.
ADPKD in the recipient has also been postulated to be a risk factor.
Acute rejection has also been described to be a risk factor for lymphocele formation
Clinical Presentation:
The majority of lymphoceles are asymptomatic. Depending on the size and location in relation to the graft, lymphoceles may exert pressure effects. Signs and symptoms include:
Graft dysfunction
Renal artery or vein thrombosis
Hydroureter or hydronephrosis
Abdominal discomfort
Abdominal pain
Backache
Wound dehiscence
Diagnosis:
The primary modality of diagnosis is imaging
USS is the gold standard for diagnosing lymphoceles as it can be used both as a diagnostic and diagnostic modality. USS guided aspiration of the contents can help to differentiate from a urinary leak and urinoma.
Treatment:
The vast majority of lymphoceles are asymptomatic and self limiting and do not require treatment. In the absence of any pressure effects on USS, such lymphoceles can be monitored with serial USS
If the lympocele is large and causing pressure symptoms, graft dysfunction, sepsis or fistula formation, then it will require treatment.
The treatment options include:
Intra-operative drain placement: It has not been shown to conclusively reduce the incidence of lymphocele formation
Percutaneous aspiration and sclerotherapy: Some clinicians recommend placement of a drain to minimize re-accumulation but there is a risk of infection
Laparoscopic fenestration: Large lymphoceles can be opened into the peritoneal cavity by making fenestrations in the lymphocele capsule. This allows for lymph to be internally drained into the peritoneal cavity. The presence of infection of the lymphocele needs to be carefully excluded before this procedure is carried out as it can lead to peritonitis
Open surgery This is carried out in the presence of infection where laparoscopic fenestration is not feasible. Open drainage carries a significantly higher risk of ureteric damage.
Conclusion:
Lymphocele formation post-transplant is fairly common. The risk factors for lymphocele formation are surgical (most common) or non-surgical. Majority of the lymphoceles are asymptomatic and resolve spontaneously. The large lymphoceles that cause pressure symptoms and lead to graft dysfunction and will need treatment. The treatment options include percutaneous drainage, laparoscopic fenestration and open drainage
The level of evidence is V
hussam juda
2 years ago
INTRODUCTION
· lymphocele may occur due to multiple factors including: damage to host retroperitoneal lymphatics, and donor lymphatics accompanying the allograft
· The incidence of symptomatic lymphocele is much lower than asymptomatic incidence
· The peak incidence at 6 weeks post-transplant, but it may occur at 1W or several months to years
PATHOPHYSIOLOGY AND RISK FACTORS
·Surgery related risk factors:
1.damage to hilar lymphatics (at the time of nephrectomy or during ‘back-table’ dissection)
2. the presence of the allograft and associated inflammatory processes increase lymph flow from the renal hilum as well as from the lymphatics around iliac vessels
3. Laparoscopic donor nephrectomy
4. donor kidneys with complex arterial anatomy
·Non-surgical risk factors:
1. Diabetes in the recipient proved to be an independent risk factor
2. Adult polycystic kidney disease in the recipient
3. Obesity in the donor
4. Increased recipient age
5. Increased warm ischaemia time
6. Acute tubular necrosis and delayed graft function
7. Prolonged pre-transplant dialysis
8. Re-transplantation
CLINICAL PRESENTATION
·Most of lymphoceles are asymptomatic and are discovered accidently during imaging
·may cause pressure effects according to size, extension, and location
·Impaired graft function due to pressure on the hilar vessels
·Hydronephrosis due to pressure on the ureter
·Pressure on the recipient iliac vein or compression of lymph drainage may lead to unilateral limb oedema, scrotal or vulval oedema and deep vein thrombosis of the iliac veins
·Large lymphoceles may cause abdominal discomfort, pain, urgency and backache
·Association with wound dehiscence can lead to sepsis or lympho-cutaneous fistula
DIAGNOSIS
· USS can determine the collection and its dimensions, location, and possible effects on the graft vessels and ureter
· USS guided aspiration, and analysis of the fluid, differentiate it from urinary leak and urinoma
· Complex echo pattern with internal debris within the collection is suggestive of complicated infected lymphocele
· CT may differentiate safe lymphoceles from infected ones and hematomas
· Higher levels of CK in the fluid may suggest that recipient is the origin of lymphocele
TREATMENT
· Asymptomatic lymphoceles mostly self-limited
· Intervention indicated if there are pressure effects causing symptoms, graft dysfunction, evidence of sepsis or fistula formation
· Intra-operative drain placement is controversial
· Percutaneous aspiration: safe, diagnostic and therapeutic
· Repeated sclerotherapy effect is questionable
· Laparoscopic fenestration: high rates of success with a minimal rate of recurrence, low morbidity, low hospital stays, but infection should be excluded before.
· Open surgery: for infected lymphocele, or laparoscopic fenestration not possible, lower pole lymphocele or complex lymphoceles causing vascular compromise
CONCLUSION
· Lymphocele is common but mostly asymptomatic and self-limited
· close surveillance is required to rule out pressure effects on the graft and possible secondary infection
· Symptomatic or complicated lymphoceles require prompt intervention with minimal morbidity to the graft as well as the patient
· Recurrent or large lymphoceles are best treated by laparoscopic fenestration, and if not possible, open surgical de-roofing indicated
What is the level of evidence provided by this article?
Narrative review level 5
Rihab Elidrisi
2 years ago
lymphocyte post kidney transplan
this is can happened in the early post operative up to 6 weeks with collection between the bladder and the graft kidney
can happen up to 34 % post RTX and it is asymptomatic in most of cases
large lympocele which is originated from kidney hilum can obstruct the kidney and need surgical intervention
· Diagnosis:
o US to detect site, size and extent of the swelling (anechoic).
o Biochemical analysis of the aspirated fluid for creatinine, electrolytes, protein content, gram stain and culture.
o Comparison with simultaneous samples taken from serum and urine for creatinine and electrolytes often become invaluable in differentiating from urinoma
o Diagnosis of infected collection by Complex echo pattern with internal debris within the collection (hyperechoic) or confirmed by CT.
o Recipient origin lymph may demonstrate higher levels of CK than that of donor origin.
usually lymphocyte of more than 500ml is usually need to be drained Laparoscopic fenestration of lymphocele to be drained through peritoneal lymphatics into the thoracic duct. infection must be excluded before this procedure, it is indicated for large lymphocele. it has low risk of recurrence (4-8%).
· laproscopic approach is better than open surgical procedure to minimize handling and damage of ureters.
· open de-roofing (Open approach for lymphocele drainage to the peritoneal cavity) has recurrence rate of 16%
mai shawky
2 years ago
club 3, lymphocele post kidney transplantation Summary
· Lymphocele means abnormal collection of lymphatic fluid that lacks an epithelialized cover, usually occurring at a site of extensive surgical dissection.
· The incidence varies between 0.6-34%, so it is a common complication however, mostly it is asymptomatic and accidently discovered in US.
· Peak incidence after 6 weeks from transplantation, however it can occur early in 1st 2 weeks, or late months or years after transplantation.
· large lymphocele and that related to the hilum can be presented with obstructive symptom, graft dysfunction and lower limb edema, in such cases, surgical treatment is necessary.
· Etiology and risk factors:
o Surgical: damage of kidney lymphatics during native nephrectomy or on the dissection on back table. diathermy does not stop leaking lymph vessels. laparoscopic native nephrectomy and kidneys with multiple or complex vasculature have higher risk.
o Medical issues:
§ Recipient risk factors: as old age, prolonged ischemia time, diabetes and ADPCKD as huge kidney will compress and impair lymphatic drainage, use of immunosuppressives as sirolimus and r ATG may be associated with risk of lymphocele, occurance of acute rejection episodes with inflammation induced lymphangectasia, use of LMWH post transplant.
§ Donor factors: as obesity
· Clinical presentation; depends on site, size and extent.
o Most of cases are asymptomatic, discovered accidently in US.
o large one compresses hilar vessels causing their thrombosis (presented with acute graft dysfunction) , compressing ureters causing hydrouretronephrosis. compressing iliac vessels causing DVT and unilateral limb and genital edema.
o Huge one compresses the bladder (urgency) and causes abdominal pain and discomfort.
· Diagnosis:
o US to detect site, size and extent of the swelling (anechoic).
o Biochemical analysis of the aspirated fluid for creatinine, electrolytes, protein content, gram stain and culture.
o Comparison with simultaneous samples taken from serum and urine for creatinine and electrolytes often become invaluable in differentiating from urinoma
o Diagnosis of infected collection by Complex echo pattern with internal debris within the collection (hyperechoic) or confirmed by CT.
o Recipient origin lymph may demonstrate higher levels of CK than that of donor origin.
· Management:
o Asymptomatic or small cephalic lymphocele (away from hilar compression) : (after exclusion of vascular or ureteric compression), just follow up US .
o Symptomatic one (>140 ml): causing compressive symptoms, as graft dysfunction, sepsis or fistula formation require definitive intervention. (0.04-14.6% of reported lymphoceles)
o US guided aspiration is best intervention , to allow also fluid analysis and differentiation from urinoma. Percutaneous drain to minimise reaccumulation, but has high risk of infection.
o Sclerotherapy after US guided aspiration as (povidone iodine, fibrin glue, 95% ethanol, fibrinogen, sodium tetradecyl sulphate and tetracycline) helps to sclerose open lymphatics.
o Repeated instilling of sclerosants may be needed, but it is associated with increased risk of nfections.
o Intraoperative placement of retroperitoneal drains adjacent to the graft may decrease the incidence of lymphocele, however, it is not the standard of care (individualized approach).
· Outcomes:
o The recurrence rate between 10-95% (mean 59%), compared to 50% with percutaneous drain placement.
o lymphocele >500 ml were unlikely to resolve with percutaneous aspiration, sclerotherapy or drain placement.
· Laparoscopic fenestration of lymphocele to be drained through peritoneal lymphatics into the thoracic duct. infection must be excluded before this procedure, it is indicated for large lymphocele. it has low risk of recurrence (4-8%).
· laproscopic approach is better than open surgical procedure to minimize handling and damage of ureters.
· open de-roofing (Open approach for lymphocele drainage to the peritoneal cavity) has recurrence rate of 16%
o indications:
§ Presence of infection for external drainage
§ Lower pole of the graft or complex lymphoceles causing vascular compromise
§ conversion from laposcopic to open may be indicated in technical difficulty, presence of peritoneal adhesions, thick, impenetrable capsule of the lymphocele and injury to abdominal viscus.
I like your summary and analysis. I agree it is level 5 evidence. We, in Liverpool, have never used sclerosants for lymphocele or any other collection related to transplant. Ajay
Ghalia sawaf
2 years ago
PATHOPHYSIOLOGY AND RISK FACTORS Surgery related risk factors
the most common are the surgical risk factors involving the donor and recipient operation.
During donor kidney procurement, hilar lymphatics may be damaged either at the time of nephrectomy or during ‘back-table’ dissection.
• Laparoscopic donor nephrectomy-
• donor kidneys with complex arterial –
• contralateral iliac fossa placement –
• and implantation to external iliac vessels
have been implicated with a higher incidence
Non-surgical risk factors
• Use of tacrolimus,
• the incidence of AR
• diabetes in the recipient
were all found to be significant in univariate analysis.
However, during the multivariate analysis, only diabetes in the recipient proved to be an independent risk factor
• Adult PCKD in the recipient has also been described as a potential risk factor
• Obesity in the donor (BMI>30) has also been described as an independent risk factor
The correlation between the incidence of lymphocele and the use of different immunosuppressive agents is controversial. ((((Sirolimus)))))
rabbit ATG induction.
LMWH after transplantation.
. . Other risk factors:
• increased recipient age,
• increased warm ischaemia time
• acute tubular necrosis
• and delayed graft function
• prolonged pre-transplant dialysis
• retransplantation
patients with symptomatic lymphoceles had a significantly higher incidence of acute rejection compared to those who had no lymphoceles (51% vs. 20%).
CLINICAL PRESENTATION
• The vast majority of lymphoceles are asymptomatic
• Depending on the size, extent and location in relation to the allograft, lymphoceles may exert pressure effects causing symptomatic presentation.
• Pressure on the hilar vessels can lead to impaired graft function and may even lead to catastrophic renal artery or vein thrombosis in rare instances where it goes undetected.
• Pressure on the ureter may lead to hydroureter or hydronephrosis of the graft.
• Pressure on the recipient iliac vein or compression of lymph drainage may lead to unilateral limb oedema, scrotal or vulval oedema and deep vein thrombosis of the iliac veins.
• Large lymphoceles may cause abdominal discomfort, pain, urgency (due to bladder compression) and backache (sacral nerve compression).
• Association with wound dehiscence can lead to sepsis or lympho-cutaneous fistula.
DIAGNOSIS
• USS can determine the collection , location , possible effects on the graft vessels and ureter
• it guided aspiration, and biochemical analysis of contained fluid allows differentiation from urinary leak and urinoma.
The biochemical analysis should be done for creatinine, electrolytes, protein content, gram stain and culture.
Complex echo pattern with internal debris within the collection and hyper-echoic appearance are more indicative of complicated infected lymphocele
imaging with CT can also assist in differentiating innocuous lymphoceles from infected ones and other collections such as hematomas.
TREATMENT
The vast majority are self limiting
In the absence of any demonstrable pressure effects or evidence of infection, such lymphoceles can be safely left alone with periodic imaging surveillance.
The decision to intervene depends on definitive pressure effects causing symptoms, graft dysfunction, evidence of sepsis or fistula formation.
lymphoceles requiring definitive intervention varies between 0.04-14.6%
1- Intra-operative drain placement
Some studies have shown that drains placed intraoperatively decrease the incidence of lymphocele. However, other authors have reported contrary outcomes where drain placement showed no benefit in reducing posttransplant lymphocele
2- Percutaneous aspiration and sclerotherapy
Symptomatic lymphoceles can be aspirated under USS guidance and remain the safest mode of intervention where needed.
It also allows for sampling of the collection to establish its true nature and rule out infection.
Seroma may not appear again, if aspiration is really indicated. However, lymphocele would not be treated just by aspiration.
Some clinicians recommend placement of a percutaneous drain to minimise reaccumulation, but external drainage always get infected.
percutaneous drainage followed by sclerotherapy,
but it is mentioned here only for condemnation.
simple aspiration alone was associated with a recurrence rate between 10-95% (mean 59%), compared to 50% with percutaneous drain placement.
Different sclerosing agents
povidone iodine, fibrin glue, 95% ethanol, fibrinogen, sodium tetradecyl sulphate and tetracycline
several case reports have reported direct graft injury and graft loss as a result of sclerosant installation
3- Laparoscopic fenestration
Large lymphoceles can be opened into the peritoneal cavity
In patients who are fit to undergo general anesthesia, this can be performed by laparoscopic fenestration.
However, the presence of infection in the lymphocele needs to be carefully excluded before this procedure.
Laparoscopic fenestration has shown high rates of success with a minimal rate of recurrence (4-8%)
lower procedure-related morbidity, and reduced overall hospital stay compared to open surgical drainage.
4- Open surgery
is required in the presence of infection (external drainage) or where laparoscopic fenestration is not possible.
Lymphoceles located in relation to the lower pole of the graft or complex lymphoceles causing vascular compromise is best treated by open de-roofing.
However, open drainage carries a significantly higher risk of ureteric damage
Hi Dr Ghalia, I like your summary and analysis. I agree it is level 5 evidence. We, in Liverpool, have never used sclerosants for lymphocele or any other collection related to transplant. I could not understand the usage of small as well as larger bolt points. Ajay
Abdul Rahim Khan
2 years ago
Please summarise this article Post transplant lymphocele is multifactorial and the incidence is 0.6 to 34%. It is well recognised morbidity and can present as merely collections, graft dysfunction, vascular compromise or sepsis. Peak incidence is usually at week 6 post transplant. Risk factors Surgical Risk factors Damage to lymphatics during hilar surgery or Bench surgery Use of diathermy rather than ligation to divide lymphatics Complex vascular anatomy requiring more dissection Laparoscopic approach may be associated with higher incidence Ipsilateral vs contra lateral implant Medical Risk factors Diabetes in recipient High BMI Compression effect of native polycystic kidneys. Immune suppressive drugs use Retransplant Acute rejection Anticoagulation Presentation It will depend upon size and loaction there can be – incidental diagnosis There can pressure effect on ureter, hilar vessels, sacral nerves, illiac veins and pelvic lymphatics Investigations Ultrasound scan or CT scan Fluid analysis for creatinine, culture electrolytes and proteins. Better compare with serum samples Treatment Use of drain during surgery reduces risk Small and asymptomatic lymphoceles can be left alone Those producing compressive effects require treatment. Options include- Percutaneous aspiration and sclerotherapy laparoscopic marsupialization External drainage if infected What is the level of evidence provided by this article?
Post-transplant lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialized cover due to lymphatic disruption.
The reported incidence shows a wide variation ranging from 0.6% to 34%
The peak incidence is at 6 weeks post-transplant and may occur early as 1-2 weeks.
Risk factors: Surgical-related risk;
Damage to donor kidney lymphatics, kidneys with complex arterial anatomy carried a higher risk; laparoscopic donor nephrectomy carries a higher risk compared to open approach and implantation site ipsilateral vs contralateral placement and the degree of lymphatic disruption during dissection. Non-surgical risk factors
Diabetes in the recipient, Obesity in the donor (BMI>30), ADPKD in the recipient may compress IVC and impair the drainage. Increased recipient age, Increase WIT, ATN, DGF, prolonged pre-transplant dialysis, Re-transplantation, and the use of sirolimus, mycophenolate and prednisolone combination may increase the risk. The use of LMWH post-transplantation may impair the sealing of damaged lymphatics. Acute rejection is involved with increased lymphangiogenesis that is associated with lymphocele.
CLINICAL PRESENTATION
Depending on the size, extent and location.
The majority are asymptomatic and detected incidentally.
Symptomatic lymphocele may cause pressure symptoms depending on the site; Pressure on the hilar vessels; graft dysfunction, RAT or RVT. Pressure on the ureter; hydroureter or hydronephrosis. Pressure on the iliac veinor lymph drainage: edema and DVT Bladder compression, abdominal discomfort, pain, urgency
Sacral nerve compression backache
Association with wound dehiscence can lead to sepsis or lympho-cutaneous fistula.
DIAGNOSIS
-US; dimensions, location, pressure effects, echogenicity, and aspiration.
-Biochemical analysis of drained fluid (creatinine, electrolytes, protein content, gram stain and culture).
-Comparison with simultaneous serum samples to differentiate urinary leak and urinoma
TREATMENT
Intra-operative drain placement reduces the risk
The majority do not require specific treatment if there are no pressure symptoms or infection.
If symptomatic (pressure-causing symptoms, graft dysfunction, sepsis or fistula formation). – Percutaneous aspiration sclerotherapy+/-percutaneous drain.
– laparoscopic fenestration into the peritoneal cavity; high rates of success with a minimal rate of recurrence
– Open surgical de-roofing; in the presence of infection (external drainage)
Hi Dr Hadeel,
I like your summary and analysis.
I agree it is level 5 evidence.
Why is more common in recipients transplanted after laparoscopic donor nephrectomy?
Ajay
saja Mohammed
2 years ago
Summary This review article published in 2019 by JRTs
lymphoceles is one of the surgical complications post-kidney transplantation resulting in a large accumulation of lymphatic fluid with extreme surgical dissections with prevalence in the range of 0.6-34% and for symptomatic lymphocele even lower than 0.6%, the majority are asymptomatic and self-limited while in less extent some lymphoceles like perinephric lymphoceles got complicated with pressure symptoms on the graft or urinary bladder and might be symptomatic, got infected so patients can present with acute graft dysfunction, sepsis that needs intervention by ultrasound-guided drainage or surgical sclerotherapy.
This review article addresses the risk factors for lymphoceles and the available treatment options.
Risk factors
Multiple surgical and medical factors related to the recipients and donors can lead to an increase in the risk of lymphoceles, usually occurring after 6 weeks but sometimes as early as 1-2 weeks post-surgery and sometimes months later up to 1 year
it’s more with laparoscopic donor nephrectomy compared to open nephrectomy
1. Excessive surgical dissection of the recipient’s retroperitoneal lymph, or lymphatic dissection around the iliac vessels
2. Donor hilar lymphatic damage, during organ mobilization
3. a donor with multiple vessels
4. Vascular anastomosis with external iliac has more risk of lymphoceles compared to the anastomosis with common iliac or internal iliac vessels, the minimal surgical manipulations by the skillful surgeon is the key for lower the risk of lymphoceles.
Nonsurgical risk factors for lymphoceles
1. few studies reported an increased risk of lymphoceles with the use of sirolimus or everolimus with diverse results also ATG as induction IS, anticoagulation with heparin
2. recipients with DM and APCKD and the donor with obesity are considered independent risk factors for lymphoceles
3. Retransplantion (access manipulations and adhesions)
4. Acute rejection due to increased inflammation and lymphatic leak
The clinical presentation of lymphoceles depends on the size, and the site, however, most are asymptomatic and can be incidentally found during routine imaging only symptomatic large perihilar lymphocele can cause pressure symptoms on the graft or UB or hilar vessels can be associated with morbidity including graft obstruction, vascular thrombosis, and infection
Usually, diagnosis by US which can assess the size of the collection the site, and the relation to the graft and hilar vessels and ureter
Signs suggestive of infected lymphoceles includes large septate collections with internal echoes which indicate debris and hyperechoic collection compared to hypo or anechoic clear collections however for the diagnosis the US-guided drainage of such collection and to be sent creatinine and potassium level in order to differentiate from urine leak and also gram stain and culture for infective collection
Some studies reported the use of CK level to differentiate the origin of lymphocele (donor-related vs recipient ) however this will not impact the management plan
Treatment options
1. Asymptomatic small lymphocele, keep it and likely will resolve spontaneously up on follow-up images.
2. Symptomatic complicated lymphoceles need US-guided drainage and depending on the collection size may keep in subcutaneous drainage
The recurrence rate depended on the size of the collection the bigger the collection the higher the rate of recurrence > 50s, so might need injection with sclerotic agents (might increase the risk of infection) and still associated with > 30% recurrence
Surgical fenestration by laparoscopic drainage of the lymphocele to the peritoneal cavity
Open surgery is rarely indicated in large infected lymphoceles with precaution for the risk of iatrogenic injury to the ureter and it’s associated with a lower rate of recurrence of < 14% compared to laparoscopic fenestration. What is the level of evidence provided by this article?
Narrative review level 5 of evidence
HiDr Saja,
I like your summary and analysis.
I agree it is level 5 evidence.
Why is more common in recipients transplanted after laparoscopic donor nephrectomy?
Ajay
Huda Al-Taee
2 years ago
Summary:
Pathophysiology and risk factors:
Surgery-related risk factors:
During donor kidney procurement, hilar lymphatics may be damaged either at the time of nephrectomy or during ‘back-table’ dissection. These damaged lymphatics continue to leak lymph after reperfusion and can contribute to lymphocele formation.
If dissected lymphatics around iliac vessels are ligated or clipped, they would leak lymph.
Diathermy does not close lymph vessels.
the presence of the allograft and associated inflammatory processes increase lymph flow from the renal hilum as well as from the lymphatics around iliac vessels, resulting lymphocele formation due to lymph leakage.
Laparoscopic donor nephrectomy has been implicated with a higher incidence of lymphocele compared to open nephrectomy.
Non-surgical risk factors
. Use of tacrolimus, the incidence of acute rejection and diabetes in the recipient, were all found to be risk factors in multivariate analysis.
Adult polycystic kidney disease in the recipient has also been described as a potential risk factor.
Obesity in the donor.
use of different immunosuppressive agents is controversial.
study showed a higher incidence of lymphocele with the use of low molecular weight heparin after transplantation.
increased recipient age, increased warm ischaemia time, acute tubular necrosis and delayed graft function, prolonged pre-transplant dialysis and re-transplantation.
acute rejection of the graft has been described as an independent risk factor for the incidence of lymphocele.
Clinical Presentation:
The vast majority are asymptomatic and are detected as incidental findings on imaging.
Symptomatic presentation depending on the size, extent, and location in relation to the allograft.
Pressure on the hilar vessels can lead to impaired graft function and may even lead to a catastrophic renal artery or vein thrombosis in rare instances.
Pressure on the ureter may lead to hydroureter or hydronephrosis of the graft.
Pressure on the recipient’s iliac vein or compression of lymph drainage may lead to unilateral limb oedema, scrotal or vulval oedema and deep vein thrombosis of the iliac veins.
Large lymphoceles may cause abdominal discomfort, pain, urgency (due to bladder compression) and backache (sacral nerve compression).
Association with wound dehiscence can lead to sepsis or lympho-cutaneous fistula.
Diagnosis:
imaging: US can determine the collection as well as its dimensions, location in relation to the graft and possible effects on the graft vessels and ureter.
US-guided aspiration and biochemical analysis of contained fluid allow differentiation from urinary leak and urinoma.
US appearance can also indicate the possible presence of infection within the collection.
e. Further imaging with computerised tomography can also assist in differentiating innocuous lymphoceles from infected ones and other collections such as hematomas.
some studies suggest differences in the creatine kinase levels of the fluid based on its source.
Treatment:
The majority of asymptomatic lymphoceles are self-limiting and do not require specific treatment.
The decision to intervene depends on definitive pressure effects causing symptoms, graft dysfunction, and evidence of sepsis or fistula formation.
Intra-operative drain placement
The placement of retroperitoneal drains adjacent to the graft at the time of transplantation is a practice performed by many surgeons.
These are usually removed once the drainage becomes negligible or before hospital discharge.
this practice remains an individual choice of the surgeon based on individual practice and patient characteristics.
Percutaneous aspiration and sclerotherapy
Symptomatic lymphoceles can be aspirated under US guidance and it allows for sampling of the collection to establish its true nature and rule out infection.
Some clinicians recommend placement of a percutaneous drain to minimise re-accumulation, but external drainage always gets infected.
The percutaneous drainage can be followed by sclerotherapy to sclerose open lymphatics, different sclerosing agents have been described in various studies with varying degrees of success, like povidone iodine, fibrin glue, 95% ethanol, fibrinogen, sodium tetradecyl sulphate and tetracycline.
several case reports have reported direct graft injury and graft loss as a result of sclerosant installation.
Laparoscopic fenestration
Large lymphoceles can be opened into the peritoneal cavity by making fenestrations in the lymphocele capsule; this can be performed by laparoscopic fenestration.
the presence of infection in the lymphocele needs to be carefully excluded before this procedure.
Laparoscopic fenestration has shown high rates of success with a minimal rate of recurrence.
Open surgery
Open surgical drainage of lymphocele is required in the presence of infection or where laparoscopic fenestration is not possible.
Lymphoceles located in relation to the lower pole of the graft or complex lymphoceles causing vascular compromise is best treated by open de-roofing.
open drainage carries a significantly higher risk of ureteric damage and needs to be performed with the utmost care.
Hi Dr Huda,
I like your summary and analysis.
I agree it is level 5 evidence.
Why is more common in recipients transplanted after laparoscopic donor nephrectomy?
Ajay
Please summarise this article
-A lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialized cover, usually occurring at a site of extensive surgical dissection.
-In renal transplantation, a lymphocele may occur adjacent to the graft, due to multiple factors including damage to host retroperitoneal lymphatics as well as donor lymphatics accompanying the allograft.
– The incidence is ranging from 0.6% to 34%.The peak incidence of lymphoceles has been reported at 6 weeks post-transplant. PATHOPHYSIOLOGY AND RISK FACTORS Surgery related risk factors
– The most common are the surgical risk factors involving the
donor and recipient operation.
-Laparoscopic donor nephrectomy has been implicated with a higher incidence of lymphocele compared to open nephrectomy. The donor kidneys with complex arterial anatomy carried a higher risk of lymphocele compared to grafts with single renal artery .
– The ipsilateral placement of the kidney and implantation to the common iliac vessels compared to contralateral iliac fossa placement and implantation to external iliac vessels was associated with a lower incidence of lymphocele . Non-surgical risk factors –Diabetes and adult polycystic kidney disease in the recipient proved to be an independent risk factors.
-Obesity in the donor (BMI>30) is independent risk factor for the occurrence of lymphocele .
-There is higher incidence of lymphocele with the use of sirolimus, mycophenolate and prednisolone combination and rabbit anti-thymocyte globulin induction..
– Higher incidence of lymphocele with the use of low molecular weight heparin after transplantation.
– The acute rejection of the graft is an independent risk factor for the incidence of lymphocele. CLINICAL PRESENTATION
-The vast majority of lymphoceles are asymptomatic .
-Depending on the size, extent and location in relation to the allograft, lymphoceles may exert pressure effects causing symptomatic presentation. DIAGNOSIS
-The primary modality in diagnosis is imaging. USS can determine the collection as well as its dimensions, location in relation to the graft and possible effects on the graft vessels and ureter .
-USS guided aspiration, and biochemical analysis of contained fluid allows differentiation from urinary leak and urinoma. The biochemical analysis should be done for creatinine, electrolytes, protein content, gram stain and culture. Comparison with simultaneous samples taken from serum and urine for creatinine and electrolytes often become invaluable in differentiating from urinoma. TREATMENT
-The vast majority of asymptomatic lymphoceles are self-limiting and do not require specific treatment.
– The decision to intervene depends on definitive pressure effects causing symptoms, graft dysfunction, evidence of sepsis or fistula formation: Intra-operative drain placement
The placement of retroperitoneal drains adjacent to the graft at the time of transplantation is a practice performed by many surgeons. Percutaneous aspiration and sclerotherapy
Symptomatic lymphoceles can be aspirated under USS guidance and remain the safest mode of intervention where needed. Laparoscopic fenestration
Large lymphoceles can be opened into the peritoneal cavity by making fenestrations in the lymphocele capsule. This allows for lymph to be internally drained to the peritoneal cavity whereby the peritoneal lymphatics would drain it into thoracic duct. Open surgery
Open surgical drainage of lymphocele is required in the presence of infection (external drainage) or where laparoscopic fenestration is not possible (internal drainage to the peritoneum). What is the level of evidence provided by this article?
Level 5
Hi Dr Reem,
I like your summary and analysis.
I agree it is level 5 evidence.
Why is more common in recipients transplanted after laparoscopic donor nephrectomy?
Ajay
Mohammad Alshaikh
2 years ago
Please summarise this article Introduction: Lymphocele is an abnormal lymphatic fluid collection due disrupted epithelized cover of lymphatics. It incidence ranges from 0.03%-26%. Usually occurs 6 weeks after kidney transplant (ranges from 2 weeks – years post transplant ). Pathophysiology: Surgical causes: damage to the hilar lymphatics while taking the donor’s kidney, inflammatory process after implanting the allograft will increase lymph flow, laparoscopic nephrectomy more at risk, dissection around the external iliac vessels, deceased donors , and complex arterial anatomy are at risk. Non-surgical causes: use of ATG, tacrolimus, diabetic recipient, acute rejection, adult polycystic kidney disease in the recipient, delayed graft function, increase warm ischemia time, prolonged time on dialysis before transplant, and obesity. Clinical presentations: usually asymptomatic, pressure symptoms- hydronephrosis, scrotal swelling , unilateral lower limb edema, and DVT. Diagnosis: usually diagnosed by ultrasound after aspiration of fluid and send for creatinine, potassium, protein, gram stain, and culture, to differentiate from urine leak/urinoma. CT can be used for diagnosis, differentiating innocuous lymphoceles from infected ones and hematomas. Treatment: Intra-operative drain placement. Percutaneous aspiration and sclerotherapy- success rate depends on the amount of the collection. Laparoscopic fenestration- safer and lower morbidity, and recurrence rate. Open surgical drainage (deroofing) of lymphocele- carries higher risk of ureteric injury and morbidity. Conclusion: Lymphocele is a major post transplantation, usually asymptomatic, diagnosed by USS guides aspiration and analysis of fluid, mostly self limited, sometimes treated by drainage or laparoscopic fenestration.
What is the level of evidence provided by this article? Level of evidence V
Hi Dr Alshaikh,
I like your summary and analysis.
I agree it is level 5 evidence.We, in Liverpool, have never used sclerosants for lymphocele or any other collection related to transplant.
Ajay
Esraa Mohammed
2 years ago
INTRODUCTION
*A lymphocele is an abnormal collection of lymphatic fluid
that lacks an epithelialized cover, usually occurring at a site
of extensive surgical dissection.
*A peri-graft lymphocele is well-recognised morbidity
following renal transplantation and can manifest in a broad
spectrum of clinical presentations
*This can range from indolent collections that cause graft dysfunction, vascular compromise or sepsis.
*The peak incidence of lymphoceles has been reported at 6 weeks post-transplant Or as early as 1-2 weeks after transplant.
*The incidence of symptomatic lymphocele is much lower and has been reported at a mean of 5.2% (range 0.03-
26%)
PATHOPHYSIOLOGY AND RISK FACTORS
Surgery related risk factors
The most common are the surgical risk factors involving the
donor and recipient operation.
Laparoscopic donor nephrectomy has been implicated with a higher incidence of lymphocele compared to open nephrectomy.
Non-surgical risk factors
1- Diabetes in the recipient AND acute rejection of the graf are independent risk factors.
2- Adult polycystic kidney disease in the recipient
3-Obesity in the donor (BMI>30)
4- Immunosuppressive agents (sirolimus, mycophenolate and prednisolone combination)with the use of rabbit antithymocyte globulin induction.
5-Use of low molecular weight heparin after transplantation.
6- Other risk factors; increased recipient age, increased warm ischaemia time, acute tubular necrosis and delayed graft function, prolonged pre-transplant dialysis and retransplantation.
CLINICAL PRESENTATION
1- The vast majority of lymphoceles are asymptomatic and are detected as an incidental finding on imaging
2- Depending on the size, extent and location in relation to the allograft, lymphoceles may exert pressure effects causing symptomatic presentation.
-Pressure on the hilar vessels >> impaired graft function or
catastrophic renal artery or vein thrombosis in rare instances
-Pressure on the ureter>> hydroureter or hydronephrosis of the graft.
-Pressure on the recipient iliac vein or compression of lymph drainage >> unilateral limb oedema, scrotal or vulval oedema and deep vein thrombosis of the iliac veins.
3-Large lymphoceles may cause abdominal discomfort, pain, urgency (due to bladder compression) and backache (sacral nerve compression).
Association with wound dehiscence can lead to sepsis or lympho-cutaneous fistula
DIAGNOSIS
1- USS guided aspiration, and biochemical analysis of contained fluid allows differentiation from urinary leak and urinoma.
2-The biochemical analysis should be done for creatinine,
electrolytes, protein content, gram stain and culture, Comparison with simultaneous samples taken from serum
TREATMENT
*asymptomatic lymphoceles are selflimiting and do not require specific treatment
*The decision to intervene depends on definitive
pressure effects causing symptoms, graft dysfunction,
evidence of sepsis or fistula formation. It can be done though one of the folowing:
-Intra-operative drain placement
-Percutaneous aspiration and sclerotherapy (For Small
volume collections, only if there is clinical indication)
-Laparoscopic fenestration for Recurrent collections or large volume lymphoceles
-Open surgery.
Hi Dr Esraa,
I like your summary and analysis.
I agree it is level 5 evidence.We, in Liverpool, have never used sclerosants for lymphocele or any other collection related to transplant.
Ajay
Last edited 2 years ago by Ajay Kumar Sharma
Huda Mazloum
2 years ago
● Post-transplant lymphocele incidence is 0.6-34%.
● it may occur as early as 1-2 weeks after transplant or several months to years after transplantation.
● lymphocele occur due to damage to host retroperitoneal lymphatics as well as donor lymphatics accompanying the allograft.
● Surgical risk factors :
** Damaged hilar lymphatics
** Laparoscopic donor nephrectomy
** donor complex arterial anatomy
** Kidney contralateral placement and implantation to external iliac vessels
● Non-surgical risk factors
** Recipiant diabetes
** Recipiant polycystic kidney disease
** Obesity in the donor (BMI>30)
** use of sirolimus, mycophenolate and prednisolone combination, rabbit anti-
thymocyte globulin induction , low molecular weight heparin after transplantation.
● Other risk factors
** increased recipient age
** increased warm ischaemia time
** acute tubular necrosis
** delayed graft function
** prolonged pre-transplant dialysis
** Re-transplantation [21].
** acute rejection of the graft as well as lymphoceles is a risk factor for acute rejection
● The vast majority of lymphoceles are asymptomatic and are detected as an incidental finding on imaging.
● Pressure on the hilar vessels can lead to impaired graft function and renal artery or vein thrombosis
● Pressure on the ureter may lead to hydroureter or hydronephrosis of the graft. ● Pressure on the recipient iliac vein or compression of lymph drainage may
lead to unilateral limb oedema, scrotal or vulval oedema and deep vein thrombosis of the iliac veins.
● abdominal discomfort, pain, urgency and unilateral limb oedema
● sepsis or lympho-cutaneous fistula.
● Sepsis
● USS guided aspiration, and biochemical analysis for creatinine, electrolytes, protein content, gram stain and culture.
● USS can also indicate infection
within the collection.
● TREATMENT
** In the absence of any pressure effects or evidence of infection no treatment
** Intra-operative drain placement
**Percutaneous aspiration and sclerotherapy
** simple aspiration alone associated with a recurrence rate 10-95% compared to 50% with percutaneous drain placement.
** Laparoscopic fenestration for Large lymphoceles into the peritoneal cavity then into thoracic duct.
** Open surgical drainage in case of infection (external drainage) or where
laparoscopic fenestration is not possible (internal drainage to the peritoneum).
● Level : 5
Hi Dr Huda,
I like your summary and analysis.
I agree it is level 5 evidence.We, in Liverpool, have never used sclerosants for lymphocele or any other collection related to transplant.
Ajay
abosaeed mohamed
2 years ago
This review looks at the risk factors for lymphocele formation along with different management options and their outcomes . A lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialized cover, usually occurring at a site of extensive surgical dissection. Post-transplant lymphocele has a reported incidence of 0.6-34%. The peak incidence of lymphoceles has been reported at 6 weeks post-transplant. However, it may occur as early as 1-2 weeks after transplant and may occur several months to years after transplantation.
– Surgery related risk factors :
During donor kidney procurement, hilar lymphatics may be damaged either at the time of nephrectomy or during ‘back-table’ dissection. Laparoscopic donor nephrectomy has been implicated with a higher incidence of lymphocele compared to open nephrectomy.
– Non-surgical risk factors :
DM , obesity , ADPKD , sirolimus use , increased recipient age, increased warm ischaemia time , acute tubular necrosis and delayed graft function , prolonged pre-transplant dialysis and retransplantation.
– CLINICAL PRESENTATION :
· majority of lymphoceles are asymptomatic and are detected as an incidental finding on imaging.
· Depending on the size, extent and location in relation to the allograft, lymphoceles may exert pressure effects causing symptomatic presentation.
· Pressure on the hilar vessels can lead to impaired graft function and may even lead to catastrophic renal artery or vein thrombosis in rare instances where it goes undetected.
· Pressure on the ureter may lead to hydroureter or hydronephrosis of the graft.
· Pressure on the recipient iliac vein or compression of lymph drainage may lead to unilateral limb oedema, scrotal or vulval oedema and deep vein thrombosis of the iliac veins.
· Large lymphoceles may cause abdominal discomfort, pain, urgency (due to bladder compression) and backache (sacral nerve compression).
· Association with wound dehiscence can lead to sepsis or lympho-cutaneous fistula. The latter presentation requires careful assessment to differentiate from urinary leakage and needs prompt intervention to prevent septic complications.
– Diagnosis :
Ultrasound showing the size, relation to the kidney & possibility of infection & US guided aspiration & analysis for creatinine , electrolytes , culture , gram stain & protein content , help to differentiate between urinoma & lymphocele .
– Treatment:
· majority of asymptomatic lymphoceles are self limiting and do not require specific treatment. In the absence of any demonstrable pressure effects or evidence of infection, such lymphoceles can be safely left alone with periodic imaging surveillance. Notably, small lymphoceles located cephalad to the graft, away from the vasculature and ureter are unlikely to cause pressure effects and rarely need intervention.
· The decision to intervene depends on definitive pressure effects causing symptoms, graft dysfunction, evidence of sepsis or fistula formation.
· Options are :
1-Intra-operative drain placement
2-Percutaneous aspiration and sclerotherapy
3-Laparoscopic fenestration
4-Open surgery
I like your summary and analysis. I agree it is level 5 evidence. Ajay
KAMAL ELGORASHI
2 years ago
Summary of the article; Introdauction; Lymphocele is an abnormal collection of lymphatic fluid following surgery, due to in part to the damage of the host retroperitoneal lymphatics, and a donor lymphatics associated with the graft, it usually around the graft in kidney transplantation. lymphocele ia a common complication following a kidney transplant, may be asymptomatic, discovered suddenly during graft follow up, or it may be symptomatic, causing graft compression, dysfunction or sepsis. peak incidence reported 6 weeks following transplant, but it may occur as early as 1-2 weeks, or some times it occur as late as months to years. Risk factors; Surgical risk factors;
Donor surgery; hilar lymphatics damaged either during nephrectomy or during back-table dissection, so it continue produce lymph after reperfusion, and it may cause lymphocele.
laparoscopic nephrectomy associated with higher rate of lymphocele than open nephrectomy.
Saidi et al.; reported higher incidence of lymphocele in the live kidney donation, compared with DDK.
Mazzucchi et al.; reported that donor kidney with complex arteries carry higher risk of lymphocele,(12.5%), compared to kidney with single artery, (3.1%)
Sansalone et al.; reported that ipsilateral placement, and implantation to the common ilaic artery, associated with lower incidence of lymphocele, (2.1%), compared to contralateral placement and implantation to the external iliac vessels, (8.5%).
Non- surgical risk factor;
Ulrich study; non-surgical risk factor of lymphocele, was associated with TAC, DM, and AR.
APKD.
Goel et al.; higher incidence with TAC/MMF/PRED.
Langer demonstrate that TAC is an independent factor of lymphocele formation.
Tondolo et al.; Higher incidence with use of rATG.
Lundin et al.; higher incidence with LMW Heparin use post Tx.
Other; old age recipients, increased WIT, ATN, and DGF.
Clinical presentation;
Asymptomatic.
Pressure effects, (DGF, renal artery or vein thrombosis, Hydroureter or hydronephrosis).
Pressure of iliac vein or lymph drainage lead to unilateral edema, scrotal or vulval edema, and DVT of iliac vein.
Large lymphocele may cause abd. discomfort, pain, urgency, or backache.
Sepsis or lymphocutaneous fistula, if associated with wound dehiscence.
Diagnosis;
USS is the primary modality; determine location, size, and compression to adjacent vessels.
Aspiration and fluid analysis can differentiate between urine leak and lymphocele, or collection due to infection.
Uncomplicated lymphocele appear hypoechoic or anechoic, while infected lymphocele appear hyperechoic.
CT help differentiate between types of lymphocele, and also hematoma.
CK level higher in recipient lymph of origin.
Treatment;
Asymptomatic lymphocele for conservative management.
Intervension based on compression, graft dysfunction, sepsis, or fistula formation.
Intraoperative drain placement.
Percutaneous aspiration and sclerotherapy .
Laproscopic fenestration.
Open surgery; if infected lymphocele, or failed other measures.
Conclusion; Peri graftlymphocele, is a common comorbidity post renal Tx. Majority of lymphocele are asymptomatic, and required no intervention.
Symptomatic lymphocele, required intervention, ranging from aspiration, drainage, laparoscopic or open surgery in some conditions.
Hi Dr Kamal I like your summary and analysis. I agree it is level 5 evidence.We, in Liverpool, have never used sclerosants for lymphocele or any other collection related to transplant. Ajay
Last edited 2 years ago by Ajay Kumar Sharma
doaa elwasly
2 years ago
Introduction
Damage of the host retroperitoneal lymphatics and donor lymphatics accompanying the allograft can lead to formation of a lymphocele adjacent to the graft in renal transplantation.
It can present either as an incidental finding or can cause graft dysfunction, vascular compromise or sepsis.
It’s actual incidence is variable because it is usually asymptomatic,
The symptomatic lymphocele represents 5.2%.
It usually occurs 6 weeks post transplantation but it can occur earlier or later. Surgery related risk factors
Include leakage from hilar lymphatics after reperfusion if injured during the time of nephrectomy or during ‘back-table’ dissection.
Or it can leak from dissected lymphatics around iliac vessels if ligated or clipped.
The allograft and the accompanied inflammatory processes increase lymph flow from the renal hilum leading to lymphocele formation .
Laparoscopic donor nephrectomy is more liable to lymphocele formation more than open nephrectomy.
Donor kidneys with complex arterial anatomy are more susceptible to lymphocele formation more than grafts with single renal artery.
Ipsilateral placement of the kidney and implantation to the common iliac vessels had lower incidence of lymphocele compared to contralateral iliac fossa placement and implantation to external iliac vessels .
The minimal the lymphatics are disrupted the lower the incidence. Non surgical risk factors
A study by Ulrich showed that tacrolimus use , acute rejection incidence and diabetes are risk factors for lymphocele occurrence but diabetes was an independent risk factor as well as obesity.
Adult polycystic kidney can be a risk for lymphocele due to impaired lymphatic drainage caused by pressure of the polycystic kidney on the IVC.
Sirolimus, mycophenolate and prednisolone combination increases lymphocele incidence.
Other studies stated that sirolimus and r ATG each one solely can increase lymphocele incidence .
Others demonstrated that acute rejection can increase lymphocele incidence and vice versa.
Other risk factors included old recipient age, increased warm
ischaemia time , ATN and delayed graft function , prolonged pre-transplant dialysis and retransplantation. Clinical picture
It varies from being asymptomatic ,incidentally discovered which is common and symptomatizing in the forum of pressure manifestations.
If it pressed on the hilar vessels ,graft dysfunction can occur or rarely renal artery or vein thrombosis.
Graft hydroureter or hydronephrosis can occur due to pressure on the ureter while compression on the recipient iliac vein or compression of lymph drainage may lead to unilateral limb oedema, scrotal or vulval oedema and deep vein thrombosis of the iliac veins.
Large lymphoceles may cause abdominal discomfort, pain, urgency and backache.
Wound dehiscence association can lead to sepsis or lympho-cutaneous fistula which necessitate rapid intervention. Diagnosis
USS along with USS guided aspiration and biochemical analysis of the fluid for creatinine, electrolytes, protein content, gram stain and culture.
Hyperechoic lesions can be indicative of infected lymphocele.
CT can be needed for further differentiation. Treatment
Usually lymphoceles donot require intervention ,only followed regularly .
Intervention will be needed if pressure or infection signs are detected leading to graft dysfunction , sepsis or fistula . Intraoperative drain placement benefit in decreasing lymphocele risk is controversial . Percutaneous aspiration and sclerotherapy
It allows sampling and analysis to differentiate lymphocele from urinoma.
Seromas may not reoccur if aspiration was indicated.
Some studies mentioned that percutaneous drainage and sclerotherapy can be useful but this is not confirmed.
Krol et stated that lymphoceles with big volume more than 500 ml and symptomatic ones are unlikely to be cured by percutaneous aspiration, sclerotherapy or drain placement.
There are different sclerosing materials used and left for variable time ranging from 5 min -24 h, Studies reported 31 % recurrence rate with it’s usage.
Installing the sclerosants can lead to infection when repeated as well as graft injury and loss. Laparoscopic fenestration
Large non infected lymphoceles can be drained in the intraperitoneal cavity after fenestration through the thoracic duct.
It has good outcomes but some technical difficulties can lead to conversion to open surgery. Open surgery
If the previous method not applicable or if the lymphocele is infected, open surgery will ne required.
Open de-roofing is used for lower pole and complex lymphoceles.
Open surgery must be carefully done as it can cause ureteric damage. Conclusion
Perigraft lymphocele is nearly common ,it is mostly asymptomatic and self limited but needs follow up to notice any pressure effects or infection and promptly treated.
Multiple risk factors can lead to it’s occurrence.
Small sized ones can be percutaneously drained if indicated
Large sized ones can be manged by laparoscopic fenestration.
I like your summary and analysis. I agree it is level 5 evidence. Ajay
Mohamad Habli
2 years ago
This article is a review article with Level of evidence 5
Definition: Lymphocele is an accumulation of lymphatic fluid lacking an epithelial covering.
Pathogenesis: Lymphoceles in kidney transplantation are caused by the destruction of lymphatics in both the donor and recipient as a result of extensive dissection or ligation. Damaged lymphatics, unlike vessels, cannot be sealed by diathermy and hence continue to leak after transplantation.
Incidence
Lymphocele can arise in 0.6-34% of transplant recipients between 1-2 weeks and months to years following transplantation.
Risk factors for lymphocele development
Causes can be surgical and nonsurgical.
Surgical causes: A higher incidence of lymphocele is associated with laparoscopic donor nephrectomy compared to open donor nephrectomy.
Contralateral kidney transplantation, such as transplanting the right kidney on the left side or the left kidney on the right side, is linked to venous compression by the artery.
Compared to anastomosis to the common iliac vessels, anastomosis to the external iliac vessels is associated with a fourfold increase in the risk of lymphocele. Multiple arteries are associated with a higher incidence of lymphocele compared to a single artery transplant. Extended duration of thermal ischemia is also recognized as a risk factor.
Non-surgical considerations are as follow:
-The incidence of lymphocele is greater in living donor kidney transplantation than in dead donor kidney transplantation.
-Older receiver age -Second or third transplant -Recipient PCKD, DM, or obesity with a BMI greater than 30 -DGF or acute graft malfunction, especially due to AR and ATN
-Long duration of dialysis before to transplantation -Use of sirolimus, high-dose steroids, and ATG -Use of LMWH, which may affect lymphatic sealing (week evidence)
Clinical presentation
Lymphocele is symptomless in the majority of cases but can present with pelvic or back ache. Graft malfunction due to urinary tract blockage or vascular compression in the presence of a large lymphocele. Urgency and frequency of urination if the urinary bladder is compressed. Secondary infection and formation of an abscess if not adequately treated.
Diagnosis
US is the primary noninvasive method for assessing the lymphocele’s location, size, and the possibility of secondary infection (hyper-echoic) or not (hypoechoic or anechoic)
CT without contrast is required for improved evaluation and exclusion of a hematoma.
Diagnostic aspiration with measurement of creatinine and potassium in the drained fluid; if it is comparable to the serum, the diagnosis is lymphocele; if it is significantly higher than the serum, the diagnosis is urinaoma; additionally, microscopy (RBCS, WBCs) and culture are required to rule out abscess transformation.
Some suggest removing an intraoperative drain when no or very little fluid is evacuated.
Therapeutic US-guided aspiration is related with a 90% recurrence rate, whereas catheter drainage is associated with a 50% recurrence rate; nevertheless, catheter drainage is associated with an increased risk of infection.
If recurrent, there are two treatment options: fenestration of the lymphocele capsule, which permits drainage of the collection into the peritoneal cavity (laparoscopic or open), or open surgical drainage (external or internal drainage), which carries a greater risk of ureteric injury.
I like your summary and analysis. I agree it is level 5 evidence. Ajay
Amit Sharma
2 years ago
Please summarise this article
Lymphocele is seen adjacent to graft kidney in 0.6 to 34% (symptomatic in 0.03% to 26%) of transplant recipients, with peak incidence at 6 weeks (seen within 1-2 weeks to months and years post-transplant).
Risk factors for lymphocele:
Surgical risk factors include damaged hilar lymphatics during donor nephrectomy, ligated or clipped lymphatics around iliac vessels, presence of inflammation, laparoscopic donor nephrectomy, donor kidney with complex arterial anatomy, contralateral iliac fossa placement and implantation to external iliac vessels.
Non-surgical risk factors include use of tacrolimus, acute rejection, diabetes in the recipient, ADPKD,obese (BMI>30) donor, use of sirolimus (alone or in combination with steroids and MMF), use of rabbit ATG, low molecular weight heparin, increased recipient age, prolonged pre-transplant dialysis vintage, re-transplantation, ATN, DGF, increased warm ischemia time.
Clinical presentation: Mostly asymptomatic, they are detected incidentally.Symptoms are due to pressure effects, which include graft dysfunction due to pressure on hilar vessels leading to thrombosis, hydroureter or hydronephrosis due to pressure on ureter, edema over scrotum/ vulva or lower limb due to pressure on lymphatics, abdominal discomfort, pain, urgency due to pressure on urinary bladder, or backache due to pressure on sacral nerve.
Diagnosis: It can be done by imaging (ultrasound) for assessing the location, dimensions and echogenicity of the collection, and aspiration of the fluid for biochemical analysis (creatinine, potassium, protein, gram stain and culture). CT scan can be used to differentiate uninfected lymphoceles from infected lymphoceles and hematomas.
Treatment: Majority asymptomatic are self-limiting. Intervention is required in presence of pressure symptoms, sepsis, fistula formation, or graft dysfunction. Laparoscopic fenestration is the treatment of choice with low recurrence rates of 4-8%. Other methods like aspiration, percutaneous drainage, sclerotherapy and open surgical drainage are not used due to high recurrence rates.
2. What is the level of evidence provided by this article?
Hi Dr Amit, We, in Liverpool, have never used sclerosants for lymphocele or any other collection related to transplant. Ajay
Abdulrahman Ishag
2 years ago
Definition;
—————————————
A lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialized cover, usually occurring at a site of extensive surgical dissection .
Surgery related risk factor.
————————————-
1-During donor kidney procurement, hilar lymphatics may be damaged either at the time of nephrectomy or during ‘back-table’ dissection.
2-If dissected lymphatics around iliac vessels are ligated or clipped, it would leak lymph.
3-The presence of the allograft and associated inflammatory processes increase lymph flow from the renal hilum as well as from the lymphatics around iliac vessels, resulting lymphocele formation due to lymph leakage.
4-Laparoscopic donor nephrectomy has been implicated with a higher incidence of lymphocele compared to open nephrectomy.
Non-surgical risk factors.
——————————————
1-Use of tacrolimus.
2-The incidence of acute rejection
3-Diabetes in the recipient
4-Adult polycystic kidney diseas.
5-Obesity in the donor (BMI>30)
CLINICAL PRESENTATION;
—————————————————————
The vast majority of lymphoceles are asymptomatic and are detected as an incidental finding on imaging.
Depending on the size, extent and location in relation to the allograft, lymphoceles may exert pressure effects causing symptomatic presentation.
1- Impaired graft function;
Pressure on the hilar vessels can lead to impaired graft function and may even lead to catastrophic renal artery or vein thrombosis in rare instances where it goes undetected.
2- Obstructive uropathy ;
Pressure on the ureter may lead to hydroureter or hydronephrosis of the graft.
3- limb oedema , scrotal or vulval oedema ;
Pressure on the recipient iliac vein or compression of lymph drainage may lead to unilateral limb oedema, scrotal or vulval oedema and deep vein thrombosis of the iliac veins.
4- Abdominal discomfort, pain ,urgency and backache ;
Large lymphoceles may cause abdominal discomfort, pain, urgency (due to bladder compression) and backache (sacral nerve compression).
5- Association with wound dehiscence can lead to sepsis or lympho-cutaneous fistula.
The latter presentation requires careful assessment to differentiate from urinary leakage and needs prompt intervention to prevent septic complications.
DIAGNOSIS;
—————————————-
1-USS can determine the collection as well as its dimensions, location in relation to the graft and possible effects on the graft vessels and ureter .
2- USS appearance can also indicate the possible presence of infection within the collection. Complex echo pattern with internal debris within the collection is more indicative of complicated infected lymphocele . An uncomplicated lymphocele appears hypoechoic or anechoic compared to the hyper-echoic appearance of an infected lymphocele.
2- USS guided aspiration, and biochemical analysis of contained fluid allows
differentiation from urinary leak and urinoma.
3- Imaging with computerised tomography can also assist in differentiating innocuous lymphoceles from infected ones and other collections such as hematomas.
4- The biochemical analysis should be done for creatinine, electrolytes, protein content, gram stain and culture. Comparison with simultaneous samples taken from serum and urine for creatinine and electrolytes often become invaluable in differentiating from urinoma.
TREATMENT;
——————————————
The decision to intervene depends on definitive pressure effects causing symptoms, graft dysfunction, evidence of sepsis or fistula formation. The reported incidence of lymphoceles requiring definitive intervention varies between 0.04-14.6%
1- Intra-operative drain placement
2- Percutaneous aspiration and sclerotherapy
3- Laparoscopic fenestration
4- Open surgery
1- Intra-operative drain placement;
——————————————————
These are usually removed once the drainage becomes negligible or before hospital discharge.
Some studies have shown that drains placed intra- operatively decrease the incidence of lymphocele . However, other authors have reported contrary outcomes where drain placement showed no benefit in reducing post- transplant lymphocele.
This practice remains an individual choice of the surgeon based on individual practice and patient characteristics.
2- Percutaneous aspiration and sclerotherapy;
—————————————————————-
Symptomatic lymphoceles can be aspirated under USS guidance .
The advantages ;
———————-
A-safe
B-It also allows for sampling of the collection to establish its true nature and rule out infection.
c-It helps in differentiation from urinoma.
The eventual success rate also depends on the size and volume of lymphoceles;
1- a volume >140 ml were symptomatic.
2- >500 ml were unlikely to resolve with percutaneous aspiration, sclerotherapy or drain placement.
It was reported that,simple aspiration alone was associated with a recurrence rate between 10-95% (mean 59%), compared to 50% with percutaneous drain placement.
Different sclerosing agents have been described in various studies with varying degrees of success.These include; povidone iodine, fibrin glue, 95% ethanol, fibrinogen, sodium tetradecyl sulphate and tetracycline .
The sclerosing agent has been instilled and kept in situ for varying periods ranging from 5 min to 24 h.
Placement of a percutaneous drain allows for continuous drainage as well as repeated instilling of sclerosants if needed. However, the chief drawbacks of repeated installation of sclerosants are the risk of introducing infection.
3- Laparoscopic fenestration;
——————————————–
Large lymphoceles can be opened into the peritoneal cavity by making fenestrations in the lymphocele capsule.
The presence of infection in the lymphocele needs to be carefully excluded before this procedure.
The indications for conversion included technical difficulty in reaching the lymphocele, peritoneal adhesions, thick, impenetrable lymphocele capsule and injury to abdominal viscus.
The advantages ;
————————
A-Laparoscopic fenestration has shown high rates of success with a minimal rate of recurrence (4-8%)
B-It carries lower procedure-related morbidity, and reduced overall hospital stay compared to open surgical drainage.
4-Open surgery;
————————————
Open surgical drainage of lymphocele is required;
1- In the presence of infection (external drainage)
2-where laparoscopic fenestration is not possible (internal drainage to
the peritoneum).
3-Lymphoceles located in relation to the lower pole of the graft or complex lymphoceles causing vascular compromise.
The reported recurrence rate following open surgical drainage to the peritoneal cavity is 16%
The disadvantages ;
————————-
A- higher risk of ureteric damage
B-needs to be performed with the utmost care in order to minimize additional morbidity.
What is the level of evidence provided by this article?
————————————————————————–
Dear Dr Ishag,
Your headings and sub-headings should be in bold or underline. That will make it easy to read.
I agree it is level 5 evidence.
Ajay
Nahla Allam
2 years ago
INTRODUCTION
Ø A lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialized cover, usually occurring at a site of extensive surgical dissection.
Ø Post-transplant lymphocele has a reported incidence of 0.6-34%
PATHOPHYSIOLOGY AND RISK FACTORS
ü Surgery-related risk factors:
Common is the surgical risk factors involving the donor and recipient operation
Laparoscopic donor nephrectomy
donor kidneys with complex arterial anatomy
the ipsilateral placement of the kidney and implantation to the common iliac vessels, compared to contralateral iliac fossa placement and implantation to external iliac vessels, was associated with a lower incidence of lymphocele (2.1% vs. 8.5%)
ü Non-surgical risk factors:
Tacrolimus use
the use of sirolimus
rabbit anti-thymocyte globulin induction.
Diabetes malleus
Adult polycystic kidney disease
CLINICAL PRESENTATION:
Ø The majorities of such lymphoceles are asymptomatic and are incidental findings on routine imaging of the allograft.
Ø Large-volume lymphoceles and those concerning the graft hilum may exert pressure effects causing potential graft dysfunction.
Ø Local symptoms may develop if the venous or lymphatic outflow of the gonads or lower limb impinges. Such symptomatic lymphoceles require definitive treatment
Ø Large lymphoceles may cause abdominal discomfort, pain, urgency (due to bladder compression) and backache (sacral nerve compression).
DIAGNOSIS:
The primary modality in diagnosis is imaging. USS
The biochemical analysis should be done for creatinine, electrolytes, protein content, gram stain, and culture.
TREATMENT
Most asymptomatic lymphoceles are self-limiting and do not require specific treatment.
Without any demonstrable pressure effects or evidence of infection, such lymphoceles can be safely left alone with periodic imaging surveillance.
The reported incidence of lymphoceles requiring definitive intervention varies between 0.04-14.6%
Intra-operative drain placement: decrease the incidence of lymphocele
Percutaneous aspiration and sclerotherapy:
Symptomatic lymphoceles can be aspirated under USS guidance and remain the safest mode of intervention where needed
Laparoscopic fenestration
Large lymphoceles can be opened into the peritoneal cavity by fenestrations in the lymphocele capsule.
Open surgery
Open surgical drainage of lymphocele is required in the presence of infection (external drainage) or where laparoscopic fenestration is not possible (internal drainage to the peritoneum). However, in this era of laparoscopy, open drainage is only of historical importance.
CONCLUSION
Peri-graft lymphocele is a reasonably common morbidity following renal transplantation. However, the vast majority of these remain asymptomatic and are self-limiting
Symptomatic or complicated lymphoceles require prompt intervention with minimal morbidity to the graft and the patient.
HI Dr Allam,
You mention risk factors of lymphocele, ‘Laparoscopic donor nephrectomy
donor kidneys with complex arterial anatomy’.
Last edited 2 years ago by Ajay Kumar Sharma
Nandita Sugumar
2 years ago
Summary : Lymphocele after renal transplant
This study is about the risk of post transplant lymphocele and the different options to manage this condition safely and effectively.
Lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialize cover occurring in areas where extensive surgical dissection has been done. The lymphocele can be found near the graft.
Surgical risk factors
Damage to hisar lymphatics leading to leakage of lymph fluid and formation of lymphocele
Laparoscopic donor nephrectomy has higher risk
Contralateral iliac fossa placement of kidney and implantation to external iliac vessels has higher risk of lymphocele formation
Minimal disruption of lymphatics is key to lowering incidence of lymphocele post transplant
Medical risk factors
Use of tacrolimus
incidence of acute rejection episodes
recipient with diabetes
adult polycystic kidney disease due to external pressure on inferior vena cava leading to impaired lymphatic drainage
obesity in donor above BMI 30
Clinical features
pressure on ureter can lead to hydrometer or hydronephrosis of graft
pressure on recipient iliac vein or compression of lymph drainage can lead to unilateral limb edema, scrotal or vulval edema and deep vein thrombosis of the iliac veins.
abdominal discomfort
pain in abdomen
urgency due to bladder compression
backache due to sacral nerve compression
wound dehiscence association can lead to sepsis or lymphocutaneous fistula
Diagnosis
Main modality is USS and USS guided aspiration – USS complex echo pattern with internal debris within the collection indicates complicated infected lymphocele
biochemical analysis of contained fluid differentiates from urinary leak and urinoma
biochemical analysis of creatinine, electrolytes, protein content, gram stain, culture.
Treatment
Asymptomatic lymphocele does not need treatment and resolves spontaneously in most cases
intraoperative drain placement
percutaneous aspiration and sclerotherapy – symptomatic lymphocele. Sclerosing agents include povidone iodine, fibrin glue, 95% ethanol, fibrinogen, sodium tetradecyl sulphate and tetracycline.
laparoscopic fenestration
open surgery – open draining of lymphocele in case of infection or when laparoscopic fenestration is not possible
Level of evidence
This is a narrative review article. Level of evidence 5.
Hi Dr Nandita,
I could not understand the risk factor for development of lymphocele, ‘Contralateral iliac fossa placement of kidney and implantation to external iliac vessels has higher risk of lymphocele formation”. We, in Liverpool, have never used sclerosants for lymphocele or any other collection related to transplant.
Ajay
Last edited 2 years ago by Ajay Kumar Sharma
Mohammed Abdallah
2 years ago
Please summarise this article
INTRODUCTION
A lymphocele is an abnormal collection of lymphatic fluid and usually occurring at a site of extensive surgical dissection
The incidence of lymphocele is variable (0.6%-34%), and lower for symptomatic (mean of 5.2%)
The peak incidence is at 6 weeks post-transplant (may be as early as 1-2 weeks and may occur months-years after transplantation)
PATHOPHYSIOLOGY AND RISK FACTORS
Surgery related risk factors (most common)
Damage of hilar lymphatics (at the time of nephrectomy or during ‘back-table’ dissection) during procurement
Laparoscopic donor nephrectomy (compared to open nephrectomy)
Donor kidneys with complex arterial anatomy (compared to grafts with single renal artery)
Contralateral iliac fossa placement and implantation to external iliac vessels
Non-surgical risk factors
Use of tacrolimus, the incidence of acute rejection and DM in the recipient (the only independent risk factor is DM)
Recipient APKD (external pressure on the IVC by the polycystic kidney resulting in impaired lymphatic drainage from the allograft and iliac region)
Donor obesity (BMI>30)
Immunosuppressive agents (controversial): sirolimus and LMWH
Other risk factors: increased recipient age, increased warm ischaemia time, ATN and DGF, prolonged pre-transplant dialysis and re-transplantation
Acute rejection
CLINICAL PRESENTATION
Mostly asymptomatic (incidental finding on imaging)
Symptomatic: pressure on hilar vessels lead to impaired graft function and renal artery or vein thrombosis. Ureter pressure leads to hydroureter or hydronephrosis . Pressure on iliac vein or compression of lymph drainage may lead to unilateral limb oedema, scrotal or vulval oedema and DVT of the iliac veins
Large lymphoceles may cause abdominal discomfort, pain, urgency (due to bladder compression) and backache (sacral nerve compression)
Sepsis/lympho-cutaneous fistula
DIAGNOSIS
USS: hypoechoic or anechoic (infected lymphocele is hyper-echoic)
USS guided aspiration and biochemical analysis of contained fluid (creatinine, electrolytes, protein content, gram stain and culture) with simultaneous samples taken from serum and urine for creatinine
Complex echo pattern with internal debris within the collection is indicative of infected lymphocele (USS)
CT (differentiating lymphoceles from infected ones and other collections such as hematomas)
TREATMENT
Most asymptomatic lymphoceles are self- limiting and do not require specific treatment (only observation if no pressure symptoms or infection)
Intra-operative drain placement
Placement of retroperitoneal drains at the time of transplantation (individual choice of the surgeon
Percutaneous aspiration and sclerotherapy
External drainage always get infected. Simple aspiration (high recurrence)
Sclerotherapy with sclerosing agent (povidone iodine, fibrin glue, 95% ethanol, fibrinogen, sodium tetradecyl sulphate and tetracycline) is associated with high recurrence rate and risk of direct graft injury and graft loss
Laparoscopic fenestration
Large lymphoceles can be opened into the peritoneal cavity by making fenestrations in the lymphocele capsule (exclude infection before the operation)
Minimal rate of recurrence (4-8%)
Lower procedure-related morbidity and reduced overall hospital stay (compared to open surgical drainage)
Open surgery
In case of infection or where laparoscopic fenestration is not possible
Lymphoceles located in relation to the lower pole of the graft or complex lymphoceles causing vascular compromise is best treated by open de-roofing
CONCLUSION
Although the majority of lymphocele are asymptomatic and self-limiting, morbidity is high with the peri-graft lymphocele
Rule out pressure effects on the graft and possible secondary infection by close surveillance
Identify patients at a high risk of lymphocele (risk factors)
Symptomatic or complicated lymphoceles require intervention, whereas small volume collections if indicated may be treated with percutaneous techniques to allow resolution
Recurrent collections or large volume lymphoceles are best treated by laparoscopic fenestration into the peritoneal cavity
What is the level of evidence provided by this article?
Ø A lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialized cover, usually occurring at a site of extensive surgical dissection. Post-transplant lymphocele has a reported incidence of 0.6-34%.
Ø The aetiology of lymphoceles may be categorised broadly based on surgical or medical risk factors. Among these, the most common are the surgical risk factors involving the donor and recipient operation
1. During donor kidney procurement, hilar lymphatics may be damaged either at the time of nephrectomy or during ‘back-table’ dissection
2. Laparoscopic donor nephrectomy has been implicated with a higher incidence of lymphocele compared to open nephrectomy
3. donor kidneys with complex arterial anatomy carried a higher risk of lymphocele
4. use of sirolimus was an independent risk factor for lymphocele formation
5. higher incidence of lymphocele with the use of rabbit antithymocyte globulin induction
6. use of low molecular weight heparin after transplantation.
7. Other risk factors implicated with lymphoceles include: increased recipient age, increased warm ischaemia time, acute tubular necrosis and delayed graft function, prolonged pre-transplant dialysis and retransplantation
Ø Clinical presentation: The vast majority of lymphoceles are asymptomatic and are detected as an incidental finding on imaging. Large lymphoceles may cause abdominal discomfort, pain, urgency (due to bladder compression) and backache (sacral nerve compression)
Ø The primary modality in diagnosis is imaging. USS can determine the collection as well as its dimensions, location in relation to the graft and possible effects on the graft vessels and ureter _ USS guided aspiration, and biochemical analysis of contained fluid allows
Ødifferentiation from urinary leak and urinoma.
Ø The vast majority of asymptomatic lymphoceles are self-limiting and do not require specific treatment. Symptomatic lymphoceles can be aspirated under USS guidance and remain the safest mode of intervention where needed.
level 5
A lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialized cover, usually occurring at a site of extensive surgical dissection.
A peri-graft lymphocele post renal transplantation has different clinical presentations.
-It can be asymptomatic
-Pressure effects on the hilar vessels
-Pressure on the ureter
-Pressure on the recipient iliac vein
– compression of lymph drainage may lead to unilateral limb oedema, scrotal or vulval odema and deep vein thrombosis of the iliac veins.
Large lymphoceles may cause abdominal discomfort, pain, urgency and backache. Association with wound dehiscence can lead to sepsis or lympho-cutaneous fistula.
DIAGNOSIS:
USS can determine the collection as well as its dimensions, location in relation to the graft and .
USS guided aspiration, and biochemical analysis of contained fluid.
TREATMENT
The majority of asymptomatic lymphoceles are self-limiting and need only imaging follow up. If causing pressure effects then:
–Percutaneous aspiration and sclerotherapy
-Laparoscopic fenestration
-or open surgery
Introduction:
A lymphocele occurs as a result of extensive surgical dissection for the donor and recipient, it occurs in the form of fluid collection without epithelial lining. It occurs usually between 2-6 weeks but may occur before 2 ws and months later on
It may be presented as indolent collections incidentally found, or may cause graft dysfunction or sepsis.
It has a variable incidence 0.6% to 34%, lack of reporting indolent cases may have a role in this wide range.
Risk factors:
Surgical: the more dissection, the more incidence.
1- Damage to donor’s at the time of nephrectomy or during ‘back-table’ dissection.
2- Iliac vessels related lymphatic dissection.
3- Laparoscopic donor nephrectomy has a higher incidence than open nephrectomy.
4- Ipsilateral placement of the kidney and implantation to the common iliac vessels has lesser rates than contralateral iliac fossa placement and implantation to external iliac vessels compared to common iliac vessels.
Non-surgical risk factors:
The diabetic recipient, ADPKD recipient, obesity, and sirolimus use.
Clinical presentation
Mostly asymptomatic
According to its size, its relation to the graft,
– Close to hilar vessels may impair graft function +/- catastrophic renal artery or vein thrombosis in rare cases.
– Hydroureter or hydronephrosis if compress ureter.
– unilateral limb edema, scrotal or vulval edema, and deep vein thrombosis if compressed iliac veins.
– Abdominal discomfort, pain, urgency and backache with large lymphocele
– Sepsis if complicated
Diagnosis
By ultrasound: clear content if not complicated, echoic lesion if complicated by infection
Aspiration and biochemical analysis to differentiate from urine leak
Treatment:
Mostly self-limiting especially if not causing compression
Percutaneous aspiration and sclerotherapy: simple and safe +/- drain insertion
Laparoscopic fenestration: after the exclusion of infection, it would be drained intraperitoneally.
level of evidence: 5
Lymphocele :
it is a collection of lymph that may occur 2-6 weeks after kidney transplantation
Pathophysiology:
-ligation of lymphatic around iliac vessels.
Risk Factors:
Recipient DM , obesity , ADPKD , mTORi
Diagnosis :
Creatinine in drain ,creatinine in fluid aspirate + US
DD:
hematoma
Complications:
hydroureter ,hydronephrosis , DVT ,fistula
Treatment:mainly conservative
DD:urinoma ,hematoma
Level 5 of evidence
A lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialized cover, usually occurring at a site of extensive surgical dissection. Post-transplant lymphocele has a reported incidence of 0.6-34%.
Risk factors
1- hilar lymphatics may be damaged either at the time of nephrectomy or during ‘back-table’
2- allograft and associated inflammatory processes increase lymph flow from the renal hilum as well as from the lymphatics around iliac vessels, resulting lymphocele formation due to lymph leakage
3- diabetes is an independent risk factor for lymphocele formation
4- Adult polycystic kidney disease
5- Obesity in the donor
6- use of low molecular weight heparin after transplantation.
7- the use of sirolimus, mycophenolate and prednisolone combination
8- acute rejection of the graft is an independent risk factor for the incidence of lymphocele
presentation
depending on the size and site, mostly asymptomatic. Pressure on the hilar vessels can lead to impaired graft function and may even lead to catastrophic renal artery or vein thrombosis in rare instances where it goes undetected. Pressure on the ureter may lead to hydroureter or hydronephrosis of the graft. Pressure on the recipient iliac vein or compression of lymph drainage may lead to unilateral limb oedema, scrotal or vulval oedema and deep vein thrombosis of the iliac veins.
Diagnosis
1st investigation include us followed by aspiration of fluid with analysis showing Similar Creatinine and Potassium to the Serum, CT Scan or MRI help in defining the anatomy and guiding the modality of treatment.
Treatment
Treatment is conservative for asymptomatic lymphocele with periodic us examination. Intervention depends on definitive pressure effects causing symptoms, graft dysfunction, evidence of sepsis or fistula formation.
This is a level V evidence article
Please summarize this article
Risk factors for lymphocele because of damaged lymphatics include:
Laparoscopic donor nephrectomy, complex arterial donor kidneys, contra-lateral iliac fossa placement and implantation to external iliac vessels. Other non-surgical factors include Tacrolimus use, acute rejection, DM, obesity and polycystic kidneys in the recipients.
Clinical presentation of lymphocele: asymptomatic in majority of cases, symptomatic compression effects: renal artery or vein thrombosis, Hydro-ureter or hydro-nephrosis, lower limb edema, scrotal or vulval edema and DVT of iliac veins.
Large lymphoceles can cause abdominal pain, urgency (bladder compression) and backache (sacral nerve compression), wound dehiscence or lympho-cutaneous fistula.
Diagnosis of Lymphocele: CT or USS guided aspiration of the collection fluid and check its serum creatinine and potassium to be compared to the serum. This fluid is to be sent for culture as well to rule out infection and abscess formation.
Treatment of Lymphocele: most of them are self-limiting as long as there are no pressure symptoms.
If there are pressure symptoms, they can be treated via:
Intra-operative drain placement, or percutaneous aspiration and sclerotherapy or Open laparoscopic fenestration or open surgery
What is the level of evidence provided by this article?
Level V
A lymphocele is an abnormal collection of lymphatic fluid without an epithelialized cover, usually occurring at a site with extensive surgical dissection.
Post-transplant lymphocele has incidence of 0.6-34%.
The incidence of symptomatic lymphocele is much less and has been found at a mean of 5.2% ;range 0.03- 26%.
The peak incidence time of lymphoceles has been reported at 6 weeks post-transplant.
Peri-graft lymphocele is common morbidity following renal Tr. However, the vast majority of cases remain asymptomatic and self-limiting. However, close surveillance is required to rule out pressure effects on the graft and possibility of secondary infection. Multiple risk factors have been reported which help in identifying patients at a higher risk of lymphocele. Symptomatic or complicated lymphoceles need urgent intervention with minimal negative impact to the graft as well as the patient. Small volume collections, if there is clinical indication, may be treated with percutaneous techniques to enhance resolution. Recurrent collections or large volume lymphoceles are optimally treated by laparoscopic fenestration into the peritoneal cavity. Open surgical de-roofing historical practice.
level 5 article.
In renal transplantation, a lymphocele may occur adjacent to the graft, due to multiple factors including damage to host retroperitoneal lymphatics as well as donor lymphatics accompanying the allograft. A peri-graft lymphocele is well-recognised morbidity following renal transplantation and can manifest in a broad spectrum of clinical presentations.
PATHOPHYSIOLOGY AND RISK FACTORS Surgery related risk factors
the donor and recipient operation. During donor kidney procurement, hilar lymphatics may be damaged either at the time of nephrectomy or during ‘back-table’ dissection. These damaged lymphatics continue to leak lymph after reperfusion and can contribute to lymphocele formation. If dissected lymphatics around iliac vessels are ligated or clipped, it would leak lymph.
the presence of the allograft and associated inflammatory processes increase lymph flow from the renal hilum as well as from the lymphatics around iliac vessels, resulting lymphocele formation due to lymph leakage
other factors surrounding the recipient and donor operation have also been recognized as potential risk factors for the incidence of lymphocele. Laparoscopic donor nephrectomy has been implicated with a higher incidence of lymphocele compared to open nephrectomy. Saidi et al. ] reported a significantly higher incidence of lymphocele with laparoscopic live donor nephrectomy compared to deceased donor transplants.
the ipsilateral placement of the kidney and implantation to the common iliac vessels compared to contralateral iliac fossa placement and implantation to external iliac vessels was associated with a lower incidence of lymphocele (2.1% vs. 8.5%). The authors postulated that there is higher lymphatic disruption associated with dissection around the external iliac compared to common iliac vessels.
Non-surgical risk factors
Adult polycystic kidney disease in the recipient has also been described as a potential risk factor . The possible explanation has been the external pressure on the inferior vena cava by the polycystic kidney resulting in impaired lymphatic drainage from the allograft and iliac region. Obesity in the donor (BMI>30) has also been described as an independent risk factor for the occurrence of lymphocele
higher incidence of lymphocele with the use of sirolimus, mycophenolate and prednisolone combination. Furthermore, Langer also demonstrated that the use of sirolimus was an independent risk factor for lymphocele formation. However, a subsequent study by Tondolo et al.failed to show any correlation based on different immunosuppressive agents including sirolimus.
significantly higher incidence of lymphocele with the use of low molecular weight heparin after transplantation. The authors postulated that the increased anticoagulant effect impaired sealing of damaged lymphatics resulting in higher incidence of lymphocele.
the acute rejection of the graft as an independent risk factor for the incidence of lymphocele. Veeramani et al. also demonstrated that patients with symptomatic lymphoceles had a significantly higher incidence of acute rejection compared to those who had no lymphoceles (51% vs. 20%). The intense inflammatory process during an episode of acute rejection is involved with increased lymphangiogenesis and lymph flow, possibly explaining its association with lymphocele.
CLINICAL PRESENTATION
The vast majority of lymphoceles are asymptomatic and are detected as an incidental finding on imaging. Depending on the size, extent and location in relation to the allograft, lymphoceles may exert pressure effects causing symptomatic presentation
Large lymphoceles may cause abdominal discomfort, pain, urgency (due to bladder compression) and backache (sacral nerve compression). Association with wound dehiscence can lead to sepsis or lympho-cutaneous fistula. The latter presentation requires careful assessment to differentiate from urinary leakage and needs prompt intervention to prevent septic complications.
DIAGNOSIS The primary modality in diagnosis is imaging. USS can determine the collection as well as its dimensions, location in relation to the graft and possible effects on the graft vessels and ureter . USS guided aspiration, and biochemical analysis of contained fluid allows differentiation from urinary leak and urinoma. The biochemical analysis should be done for creatinine, electrolytes, protein content, gram stain and culture.
difference in the creatine kinase (CK) levels of the fluid based on its source, with recipient origin lymph demonstrating higher levels of CK. However, the clinical utility of this analysis from a management perspective remains unproven.
TREATMENT
The vast majority of asymptomatic lymphoceles are selflimiting and do not require specific treatment. Once they are detected, further testing is done to establish any pressure effects on the vasculature or ureter. In the absence of any demonstrable pressure effects or evidence of infection, such lymphoceles can be safely left alone with periodic imaging surveillance. Notably, small lymphoceles located cephalad to the graft, away from the vasculature and ureter are unlikely to cause pressure effects and rarely need intervention. The decision to intervene depends on definitive pressure effects causing symptoms, graft dysfunction, evidence of sepsis or fistula formation. The reported incidence of lymphoceles requiring definitive intervention varies between 0.04-14.6%
Intra-operative drain placement
The placement of retroperitoneal drains adjacent to the graft at the time of transplantation is a practice performed by many surgeons. These are usually removed once the drainage becomes negligible or before hospital discharge.
Percutaneous aspiration and sclerotherapy
Symptomatic lymphoceles can be aspirated under USS guidance and remain the safest mode of intervention where needed. It also allows for sampling of the collection to establish its true nature and rule out infection. Percutaneous aspiration can, at the best, is a diagnostic step that helps in differentiation from urinoma.
Laparoscopic fenestration
Large lymphoceles can be opened into the peritoneal cavity by making fenestrations in the lymphocele capsule. This allows for lymph to be internally drained to the peritoneal cavity whereby the peritoneal lymphatics would drain it into thoracic duct. In patients who are fit to undergo general anesthesia, this can be performed by laparoscopic fenestration.
Open surgery Open surgical drainage of lymphocele is required in the presence of infection (external drainage) or where laparoscopic fenestration is not possible (internal drainage to the peritoneum). In this era of laparoscopy, open drainage is only of historical importance.
CONCLUSION
Peri-graft lymphocele is fairly common morbidity following renal transplantation. However, the vast majority of these remains asymptomatic and is self-limiting. Nevertheless, close surveillance is required to rule out pressure effects on the graft and possible secondary infection. Multiple risk factors have been described which helps in identifying patients at a higher risk of lymphocele. Symptomatic or complicated lymphoceles require prompt intervention with minimal morbidity to the graft as well as the patient.
W9 j 3
Iii . Lymphocele after Renal Transplantation – A New Look at an Age-Old Problem!
Q1- Please summarise this article ?
ABSTRACT
Post-transplant lymphocele incidence is 0.6-34%.
Most of these cases are asymptomatic and are found incidentally on routine imaging of the allograft. Large volume lymphoceles and those in the graft hilum can produce pressure effects causing graft dysfunction. Local symptoms may develop if venous or lymphatic outflow of gonads or lower limb is affected. Symptomatic lymphoceles need definitive treatment.
INTRODUCTION
Definition:- A lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialized cover, usually occurring at a site of extensive surgical dissection. It is occur because of damage to host and donor lymphatics .
Is well- recognised complication it has variable presentation range asymptomatic to graft dysfunction, vascular compromise or sepsis. The peak incidence is at 6 weeks post- transplant but it could present as early as 1-2 weeks after transplant or months to years after transplantation.
PATHOPHYSIOLOGY AND RISK FACTORS
Surgery related risk factors:
1- Damage to hilar lymphatics .
2- If dissected lymphatics are ligated or clipped, it would leak lymph.
3- Diathermy use which does not close lymph vessels .
4- Laparoscopic donor nephrectomy. Saidi et al. reported a higher incidence of lymphocele with laparoscopic live donor nephrectomy compared to deceased donor transplants.
Non-surgical risk factors:
1) diabetes in the recipient.
2) Adult polycystic kidney disease.
3) Obesity in the donor (BMI>30).
4) sirolimus, mycophenolate and prednisolone combination or sirolimus it self .
5) rabbit anti- thymocyte globulin induction.
6) use of low molecular weight heparin after transplantation.
7) increased recipient age.
8) increased warm ischaemia time.
9) acute tubular necrosis .
10) delayed graft function .
11) prolonged pre-transplant dialysis .
12) and re- transplantation.
CLINICAL PRESENTATION:
The vast majority are asymptomatic and are detected on imaging.Pressure presentation Depend on the size, extent and location in relation to the allograft.
This may cause
1- renal artery or vein thrombosis.
2- Hydro-ureter or hydro- nephrosis.
3- Unilateral limb edema.
4- scrotal or vulval edema.
5- deep vein thrombosis of the iliac veins.
6- pain, and urgency.
7- Backache.
8- association with wound dehiscence can lead to sepsis or lympho-cutaneous fistula.
DIAGNOSIS:
The primary modality in diagnosis is imaging by abdominal ultrasound.
USS guided aspiration, and biochemical analysis of fluid Helps to differentiation from urinary leak and urinoma. Biochemical analysis should be done for creatinine , electrolytes, protein , gram stain and culture. USS appearance can also indicate the presence of infection within the collection.
TREATMENT:
MOST of asymptomatic lymphoceles are self- limiting and do not require specific treatment.
The decision to intervene depends on definitive pressure effects causing
a) symptoms,
b) graft dysfunction,
c) evidence of sepsis or fistula formation.
incidence of lymphoceles requiring intervention is between 0.04-14.6%.
1- Intra-operative drain placement:
The placement of retroperitoneal drains aroutine practice performed by many surgeons.
2- Percutaneous aspiration and sclerotherapy:
Symptomatic lymphoceles can be aspirated under USS guidance and it is the safest intervention. It help in sampling of the collection to establish its true nature and rule out infection. simple aspiration alone associated with a recurrence rate 59% , compared to 50% with percutaneous drain placement.
3- Laparoscopic fenestration:
Large lymphoceles can be opened into the peritoneal cavity by making fenestrations in the lymphocele capsule. But infection should be excluded before this action.
4- Open surgery:
Open surgical drainage of lymphocele is required in the presence of infection (external drainage) or where laparoscopic fenestration is not possible. In this era of laparoscopy, open drainage is rarely used. Lymphoceles located in relation to the lower pole of the graft or complex lymphoceles causing vascular compromise is best treated by open de-roofing.
Q2- What is the level of evidence provided by this article?
It is level 5.
1-Please summarize this article :
Introduction :
A Lymphocele is one of the most common surgical complication post renal transplantation which may present as early as 1-2 weeks or several months to years post transplantation with incidence ranging from 0.6% to 34%
lymphocele is an abnormal fluid collection around the transplanted kidney due to surgical and medical risk factors .
Risk factors :
Clinical presentation:
The majority are asymptomatic. Symptoms may occur depending on the size , site and extent to the surrounding tissues.
Pressure effect on the hilar vessels may lead to impaired graft function or even venous or arterial thrombosis , pressure effect on ureter lead to hydro ureter and HN .
Pressure on the recipient iliac vein or compression of lymph drainage may lead to unilateral limb oedema, scrotal or vulval oedema and deep vein thrombosis of the iliac veins.
Large lymphoceles may cause abdominal discomfort, pain, urgency and backache (sacral nerve compression). Association with wound dehiscence can lead to sepsis or lympho-cutaneous fistula.
Diagnosis :
The diagnosis is realized with imaging. The simplest method is the USS, determining the collection and its dimensions, location, relationship with the graft and compression effects on the vessels and ureter. Allows guided aspiration and biochemical analysis of contained fluid allows differentiation from urinary leak and urinoma.
Treatment :
Most of the asymptomatic lymphoceles require no specific treatment but they need to be assessed and followed for any pressure effects on the vasculature or ureter. Avoidance is through placement of retroperitoneal drains adjacent to the graft at the time of transplantation.
For symptomatic ones, treatment modalities include percutaneous aspiration, sclerotherapy and laparoscopic fenestration.
Level V
1-Please summarise this article:
A lymphocele can be defined as an abnormal collection of lymphatic fluid that lacks an epithelialized cover, usually occurring at a site of extensive surgical dissection.
Post-transplant lymphocele has a reported incidence of 0.6-34%.
Risk factors include both surgical and non-surgical factors:
Surgical factors include:
Donor and recipient related factors and include damage to the hilar lymphatics during Nephrectomy or during back-table dissection , presence of allograft and the inflammatory processes all increase the lymphatics leak.also laparoscopic donor Nephrectomy and complex arterial anatomy, also ipsilateral placement of the kidney and implantation to the common iliac vessels compared to contralateral iliac fossa placement and implantation to external iliac vessels was associated with a lower incidence of lymphocele.
Non-surgical risk factors:
Use of tacrolimus
the incidence of acute rejection
diabetes in the recipient were all associated with lymphocele formation .
Adult polycystic kidney disease in the recipient .
Obesity in the donor (BMI>30) .
higher incidence of lymphocele with the use of sirolimus, mycophenolate and prednisolone combination.
higher incidence of lymphocele with the use of low molecular weight heparin after transplantation.
increased recipient age.
increased warm ischaemia time .
acute tubular necrosis and delayed graft function .
prolonged pre-transplant dialysis and re- transplantation .
Clinical presentation:
The majority are asymptomatic. Symptoms may occur depending on the size , site and extent to the surrounding tissues.
Pressure effect on the hilar vessels may lead to impaired graft function or even venous or arterial thrombosis , pressure effect on ureter lead to hydro ureter and HN .
Pressure on the recipient iliac vein or compression of lymph drainage may lead to unilateral limb oedema, scrotal or vulval oedema and deep vein thrombosis of the iliac veins.
Large lymphoceles may cause abdominal discomfort, pain, urgency and backache (sacral nerve compression). Association with wound dehiscence can lead to sepsis or lympho-cutaneous fistula.
Modality of diagnosis:
US
Biochemical analysis of drains fluid
CT scan .
TREATMENT:
Intra-operative drain placement
Percutaneous aspiration and sclerotherapy
Laparoscopic fenestration
Open surgery
2-What is the level of evidence provided by this article?
Narrative review level V
Lymphocele is a common complication after kidney transplantation, notwithstanding, majority are asymptomatic. Its prevalent in about 0.6-34% of allograft recipients. Symptomatic lymphocele reported in 5.2%.
Reported to occur as early as 1-2 weeks post-transplant and as late as years thereafter.
Risk factors are surgical and non-surgical.
Surgical risk factors are donor related and recipient related.
Donor related factors:
During harvesting the kidney, renal hilum might be injured, or secondly while preparing the allograft.
Allograft with multiple renal arteries is increasingly prone to develop lymphocele.
Laparoscopic nephrectomy of life donors is linked to heightened incidence.
Recipient related:
Extensive clipping or ligation of pelvic lymphatic around iliac vessels might re-leak. Lymphatic diathermy is non secure and associated with high recurrence of lymphatic leak.
presence of allograft with inflammation, infection or rejection is augmenting lymphatic leak.
Utilizing common iliac artery is safer for implementing the allograft then external iliac artery owing to complex anatomical field necessitating wide lymphatic dissection.
Non-surgical causes:
Sirolimus based regimen is associated with increasing incidence. Similarly, induction with ATGr was reported.
Diabetes mellitus, obesity, prolonged dialysis duration pre transplantation, Tacrolimus, acute rejection, ATN and delayed graft function.
Its mor prevalent in APCKD recipients due to compression of IVC by huge size polycystic kidney.
Clinical presentation:
Majority is asymptomatic detected by screening US post transplantation.
When its sizeable lymphocele, pressure symptoms might supervene, such as hydroureter and hydronephrosis, pressure on deep veins causing DVT, lymphatic obstruction causing testicular or labial swelling. Opening of the wound with lymphatic fistula might be encountered, a condition that predispose to superadded infection.
Diagnosis:
US study is essential in determining extent, location and potential consequences of lymphocele. As its illustrative of anechoic cystic lesion. increased opacity of the same cyst is indicative of potential complicating abscess.
aspiration and analysis of fluid simultaneously with serum is advocated in certain situation when diagnosis is in doubt.
CK was speculated to be elevated in Lymphocele fluid.
Management:
The key point indicative of necessity to commence management is pressure features, infection, allograft dysfunction and fistula.
Keeping extra-peritoneal drain is associated with lower incidence of lymphocele.
Usually, lymphocele of more than 140 ml is usually symptomatic. And more than 500 ml is unlikely to resolve with aspiration or sclerotherapy.
Fenestration of lymphocele to peritoneal cavity is the main strategy to mitigate lymphatic collection.
Open surgical drainage is indicated in infective lymphocele.
Lymphocele located near lower pole of allograft or causing vascular compromise is an indication for open surgery and de-roofing
level of evidence 5
RISK FACTORS RELATED TO SURGERY
– laparoscopic live donor nephrectomy
– complex arterial anatomy
-higher lymphatic disruption associated with dissection around the external iliac compared to common iliac vessels
NON-SURGICAL RISK FACTORS
– diabetes in the recipiente
– Adult polycystic kidney disease in the recipiente
– Obesity in the donor (BMI>30)
– increased recipient age;
– increased warm ischaemia time;
– acute tubular necrosis and delayed graft function
– prolonged pre-transplant dialysis
– retransplantation
The correlation between the incidence of lymphocele and the use of different immunosuppressive agents is controversial. Alguns estudos demonstrated a significantly higher incidence of lymphocele with the use of sirolimus, mycophenolate and prednisolone combination, ou ainda, o uso de sirolimus isolado, enquanto outros trabalhos não encontram relação.
The majority of lymphoceles are asymptomatic and are detected as an incidental finding on imaging. Depending on the size, extent and location in relation to the allograft, lymphoceles may exert pressure effects causing symptomatic presentation, for example : pressure on the recipient iliac vein or compression of lymph drainage may lead to unilateral limb oedema, scrotal or vulval oedema and deep vein thrombosis of the iliac veins. Large lymphoceles may cause abdominal discomfort, pain, urgency (due to bladder compression) and backache (sacral nerve compression).
The diagnosis is realized with imaging. The simplest method is the USS, determining the collection and its dimensions, location, relationship with the graft and compression effects on the vessels and ureter. Allows guided aspiration and biochemical analysis of contained fluid allows differentiation from urinary leak and urinoma.
The vast majority of asymptomatic lymphoceles are self-limiting and do not require specific treatment. Once they are detected, further testing is done to establish any pressure effects on the vasculature or ureter and the decision to intervene depends on definitive pressure effects causing symptoms, graft dysfunction, evidence of sepsis or fistula formation.
Possible interventions are:
– Intra-operative drain placement : there are controversial results regarding the benefit of retroperitoneal drains adjacent to the graft at the time of transplantation.
– Percutaneous aspiration and sclerotherapy: isolated aspiration may have a high recurrence rate, while drain placement may cause infection. The use of sclerosants appears as an alternative to reduce the risk of these unwanted events.
– Laparoscopic fenestration: trata-se da drenagem in peritoneal cavity. it has shown high rates of success with a minimal rate of recurrence and lower procedure-related morbidity, and reduced overall hospital stay compared to open surgical drainage
– Open surgery: necessary in presence of infection (external drainage) or where laparoscopic fenestration is not possible (internal drainage to the peritoneum)
Level evidence is 05 because is a narrative reviews
Lymphocele after Renal Transplantation – A New Look at an Age-Old Problemintroduction
Lymphocele is known cause of graft dysfunction and p==mortality.
Clinical presentation such as compression effect on the graft and subsequent graft dysfunction vascular insufficiency or sepsis.
Incidence of lymphocele is from 0.6 to 39%
It can occurs from 1-2 week post kidney transplant up to several months to years.
Pathophysiology and risk factors:
Surgery related risk factors for donor and recipient donor
Donor factors:
· Damage of lymphatics during nephrectomy.
· Clipped or ligated lymphatics and iliac vessels.
· Associated inflammatory process.
· Laparoscopic donor nephrectomy has a higher incidence of lymphocele.
· Multiple renal arteries in the donor carry a high risk of lymphocele
· Ipsilateral placement of kidney transplantation has a lower incidence of lymphocele
Nonsurgical risk factors:
Ø Adult polycystic kidney disease in the recipient
Ø Obesity in the donor BMI>30 has an independent risk factor for the occurrence of lymphocele
Ø The correlation between the incidence of lymphocele and the use of different immunosuppression agents is controversial.
Ø Other risk factors for lymphocele in kidney transplantation recipient
1. Increase recipient age
2. Acute tubular necrosis
3. Delay graft function
4. Prolong pre-transplant dialysis
5. Re transplantation
Clinical presentation:
Could be non indicated finding on imaging.
Compression symptoms include renal vein or artery thrombosis
Hydroureter
Unilateral limb oedema
Scrotal or valval oedema
Large lymphocele can cause abdominal discomfort, pain,and back pain
Diagnosis:
Ultrasonography determine the collection as well as the location
U/S quidded aspiration and biochemical analysis of contained fluid to differentiate from urine leak and urinoma
Biochemical analysis should be done for electrolytes, protein content, gram stain, and culture and sometime take creatinine and electrolytes from urine sample
CT can differentiate lymphocele from haematoma
Treatment:
Asymptomatic lymphocele is self limiting
Symptomatic lymphocele especially graft function, sepsis or fistula formation need surgical intervention
Remaining the drain in place individual choice
Percutaneous aspiration and sclerotherapy:
Symptomatic lymphocele can be aspirate under U/S guidance
Some lymphocele needs percutaneous drain to minimize re accumulation
Lymphocele volume >140ml and septic and >500ml were unlikely to resolve with percutaneous aspiration sclerotherapy or drain placement needed.
Laparoscopic fenestration:
Large lymphocele opened into peritoneal cavity by fenestration in to lymphocele capsules but first need to role out infection
Open surgery:
If infected lymphocele so surgical damage is best option or laparoscopic fenestration is not possible.
Conclusion:
Lymphocele usually a symptomatic and self-limiting
Patients been at risk due to multiple risk factors.
Symptomatic or complicated lymphocele required intervention
Laparoscopic fenestrations into the peritoneal cavity treatment option recurrent collection or large volume lymphocele.
level 5
The lymphocele are usually asymptomatic identified incidentally on imaging until unless causing pressure effects on vessels, ureter etc, and they may compromise graft function with venous thrombosis, lymphatic obstruction, if not treated urgently. some times large enough to cause abdominal discomfort, pain, pressure effect on bladder and with frequency and urgency, sacral nerve compression and some time wound dehiscence. Its very common after ureteric leak around 2 to 34%. The risk factors hilar lymphatic damage, obesity >30, diabetic, use of sirolimus.
If asymptomatic and with pressure effect can wait and observe, if symptomatic then surgical approach.
level V
1. Please summarise this article
Post-transplant lymphocele is an abnormal collection of lymphatic fluid adjacent to the graft with incidence of 0.6-34%.
RISK FACTORS:
1-Surgical risk factors: hilar lymphatics damage, increase lymph flow due to inflammatory processes, laparoscopic donor nephrectomy, donor kidneys with complex arterial anatomy , contralateral placement of the kidney and implantation to the external iliac vessels
2- Non-surgical risk factors: diabetes in the recipient, adult polycystic kidney disease in the recipient, obesity in the donor (BMI>30), use of sirolimus alone, use of sirolimus combined with mycophenolate and prednisolone, rabbit ATG induction, LMW heparin after transplantation, increased recipient age, increased warm ischaemia time, ATN and DGF, prolonged pre-transplant dialysis, retransplantation and acute rejection.
Symptoms and signs:
Mostly are asymptomatic discovered incidentally on routine imaging of the allograft. They may cause graft dysfunction, vascular compromise or sepsis. They increase the risk of acute rejection compared to those who had no lymphoceles. They might exert pressure on the hilar vessels and lead to impaired graft function, renal artery or vein thrombosis. lymphatic outflow obstruction of gonads or lower limb may lead to unilateral limb oedema, scrotal or vulval oedema and deep vein thrombosis of the iliac veins. . Pressure on the ureter may lead to hydroureter or hydronephrosis of the graft. Large lymphoceles may cause abdominal discomfort, pain, urgency and sacral nerve compression. They may end with wound dehiscence ending with sepsis or fistula.
DIAGNOSIS:
Ultrasound imaging is important in diagnosis and management through US guided aspiration. The aspirate biochemical analysis and serum analysis will differentiate it from urinary leak and urinoma (creatinine, electrolytes, protein, gram stain and culture). Presence of debris and complex echo pattern would signify infection within the collection.
TREATMENT:
Most of the asymptomatic lymphoceles require no specific treatment but they need to be assessed and followed for any pressure effects on the vasculature or ureter. Avoidance is through placement of retroperitoneal drains adjacent to the graft at the time of transplantation.
For symptomatic ones, treatment modalities include percutaneous aspiration, sclerotherapy and laparoscopic fenestration.
1. What is the level of evidence provided by this article?
Level V
What is the level of evidence provided by this article?
Level V
INTRODUCTION
A lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialized cover, usually occurring at a site of extensive surgical dissection.
In renal transplantation, a lymphocele may occur adjacent to the graft, due to multiple
factors including damage to host retroperitoneal lymphatics as well as donor lymphatics accompanying the allograft. A peri-graft lymphocele is well-recognised morbidity following renal transplantation and can manifest in a broad spectrum of clinical presentations. This can range from indolent collections detected merely as incidental findings on or those that cause graft dysfunction, vascular compromise or sepsis.
The peak incidence of lymphoceles has been reported at 6 weeks post-transplant. However, it may occur as early as 1-2 weeks after transplant and may occur several months to years after transplantation
CLINICAL PRESENTATION
It depends on the site and the size
– asymptomatic and are detected as an incidental finding on imaging.
– Pressure on the hilar vessels can lead to impaired graft function and may even lead to
catastrophic renal artery or vein thrombosis in rare instances where it goes undetected.
– Pressure on the ureter may lead to hydroureter or hydronephrosis of the graft.
– Pressure on the recipient iliac vein or compression of lymph drainage may lead to unilateral limb oedema, scrotal or vulval oedema and deep vein thrombosis of the iliac veins.
– Large lymphoceles may cause abdominal discomfort, pain, urgency (due to bladder compression) and backache (sacral nerve compression). Association with wound dehiscence can lead to sepsis or lympho-cutaneous fistula.
DIAGNOSIS
USS and or CT abdomen can determine the collection as well as its dimensions, location in relation to the graft and possible effects on the graft vessels and ureter
TREATMENT
– The vast majority of asymptomatic lymphoceles are self-limiting and do not require specific treatment especially if no compression on the adjacent graft and its vasculature
– The placement of retroperitoneal drains adjacent to the graft, These are usually removed once the drainage becomes negligible or before hospital discharge.
– Percutaneous aspiration and sclerotherapy.
– Large lymphoceles can be opened into the peritoneal cavity by making fenestrations in the lymphocele capsule.
– Open surgical drainage of lymphocele is required in the presence of infection (external drainage) or where laparoscopic fenestration is not possible
A lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialized cover, usually occurring at a site of extensive surgical dissection.
Post-transplant lymphocele has a reported incidence of 0.6-34%.
The incidence of symptomatic lymphocele is much lower and has been reported at a mean of 5.2% (range 0.03- 26%)
The peak incidence of lymphoceles has been reported at 6 weeks post-transplant.
Peri-graft lymphocele is fairly common morbidity following renal transplantation. However, the vast majority of these remains asymptomatic and is self-limiting. Nevertheless, close surveillance is required to rule out pressure effects on the graft and possible secondary infection. Multiple risk factors have been described which helps in identifying patients at a higher risk of lymphocele. Symptomatic or complicated lymphoceles require prompt intervention with minimal morbidity to the graft as well as the patient. Small volume collections, only if there is clinical indication, may be treated with percutaneous techniques to allow resolution. Recurrent collections or large volume lymphoceles are best treated by laparoscopic fenestration into the peritoneal cavity. Open surgical de-roofing is of historical importance.
level 5
Lymphocele is a collection of the lymphatic fluid at the site of surgical dissection without an epithelial cover…In renal transplantation peri graft lymphocele has been associated with variable incidence of 3 to 25% in various studies…The variable incidence has been told due to screening USG being done only if patient are symptomatic…The actual incidence of symptomatic lymphocele has been only 5%. Lymphocele usually occur within 4 to 6 weeks after transplant but chronic asymptomatic lymphocele have been reported too….
Surgery related risk factors include many hypothesis related to cause lymphatic damage…During donor nephrectomy hilar lymphatics can get damaged during nephrectomy or during the bench dissection…Improper dissection of the iliac lymphatics have been implicated in causing lymphocele especially if they are clipped or ligated they can leak alter…Diathermy does not cauterize the lymphatics as they do for the blood vessels…Persistent Graft inflammation may cause lymph ooze from the hilum and may need to lymphocele…Laparoscopic donor nephrectomy has been implicated to cause higher damage to the lymphatics as compared to the open nephrectomy techniques.. Donor kidneys with more renal arteries are known to be associated with lymph damage…some studies say that the contralateral kidney placement and use of external iliac are associated with higher degree of lymph dissection…
Non surgical risk factors are diabetes, obesity in recipients, use of sirolimus and presence of graft inflammation in rejections are known to be associated with graft lymphocele….
The vast majority of them are asymptomatic and detected only on ultrasound. Symptomatic lymphocele are when they compress the neighboring structures causing HUN, renal vein thrombosis or kinking of the renal artery etc..It can even compress the ipsilateral common iliac vein and lead to DVT, scrotal edema or vulval edema…If the lymhocele is infected it can cause pain and tenderness of the graft site adjacent to it.. Large lymphocele cause subcutaneous compression and lead to lymphocutaneous fistula
Once confirmed by USG it has to be aspirated and send for analysis to rule of infection and to confirm its only lymph and not urine…The drain fluid creatinine and potassium will be same as plasma in lymphocele and it will be very high if it is a urinoma…We should make sure there are no infections before analyzing the permanent solution for the lymphocele as aspiration of the lymphocele is associated with highest rate of recurrence….
small asymptomatic lymphocele can be left as it is…The large symptomatic lymphocele are associated with compressive symptoms need to be drained…
USG guided aspiration is the standard procedure for sampling and at the same time many authors recommend instilling sclerosing agents and keeping a drain but these techniques are associated with higher infection and need repeated interventions….Laproscopic fenestration and opening the peritoneum into the abdominal cavity and allow the abdominal lymphatics to drain the lymphocele into the thoracic duct is an alternative…It is associated with high rates of success and less rates of recurrence…
this is a review article and hence level of evidence is 5
Lymphocele after Renal Transplantation: A New Look at an Age-Old Problem!
Lymphocele is a collection of lymphatic fluid at a site with extensive dissection
It is associated with Injury to the recipient or donor lymphatics , as per site located some times it can carry great morbidity especially if it is located at the hilum of the graft.
Some were diagnosed incidentally while others presents with either graft dysfunction, vascular compression or sepsis.
Lymphocele incidence ranges from 0.3-34 % . however this is only it is discovered by imaging techniques. However it range from 0.03- 26% if it is symptomatic.
It can be collected in the couple of weeks post transplant however it reach the peak by the 6th weeks post transplant.
PATHOPHYSIOLOGY AND RISK FACTORS
Surgery related risk factors
1. During Donor kidney procurement, hilar lymphatics may be damaged either during nephrectomy or back table dissection.
2. Presence of inflammatory process around the allograft increase the lymphatic drainage.
3. Laparoscopic donor nephrectomy increases the risk
4. Donor kidney with complex arterial anatomy carries a higher risk
5. contralateral placement of the kidney
non surgical risk factors
1. use of tacrolimus
2. acute rejection
3. diabetes
4. adult PKD
5. obesity in the donor
6. combination of sirolimus/MMF and prednisolone
7. induction with rabbit ATG
8. LMWH
9. Increased recipient age
10. Increase warm ischemia time
11. Acute tubular necrosis
12. Delayed graft function
13. Prolonged pre transplant dialysis
14. Re transplantation.
Clinical presentation
1. Asymptomatic: majority
2. Other symptomatic depending on size, extent and location in relation to allograft
· Pressure effect leading to hydroureter /hydronephrosis of the graft.
· Impaired graft function
· Renal artery /vein thrombosis
· Unilateral limb edema/scrotal/valval edema
· DVT iliac vessels
· Abdominal discomfort, pain
· Urgency
· Backache
· Sepsis or lympho-cutaneous fistula
Diagnosis
Ultrasound scan to determine a collection
Uss guided aspiration and biochemical analysis to differentiate b/w urinary leak and urinoma
Analysis for : creatinine, electrolytes, protein content ,gram stain, culture
Comparing with simultaneous same from serum and urine for creatinine and electrolytes.
Treatment
Asymptomatic, usually small, can be left for reabsorption
Large or causing pressure effect/graft dysfunction/evidence of sepsis will requires intervention.
· Intraoperative drain placement
· Percutaneous aspiration with sclerotherapy.
· Laparoscopic fenestration.
. Open surgery
level of evidence 5
Lymphocele after Renal Transplantation: A New Look at an Age-Ol problem
_____________________
Summary
INTRODUCTION
▪︎ A lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialized cover, usually occurring at a site of extensive surgical dissection.
▪︎The lymphocele in renal transplantation can ocurr due to damage in host retroperitoneal lymphatics as well as donor lymphatics accompanying the allograft.
▪︎Clinical presentations of peri-graft lymphocele: range from indolent collections detected merely as incidental findings on or those that cause graft dysfunction, vascular compromise or sepsis.
◇ Risk factors of lymphocele according to different studies:
1. Damage to hilar lymphatics either at the time of nephrectomy or during ‘back-table’ dissection.
2. If dissected lymphatics around iliac vessels are ligated or clipped, it would leak lymph.
3. The presence of the allograft and associated inflammatory processes result in lymph leakage.
4. Laparoscopic donor nephrectomy.
5. Donor kidneys with complex arterial anatomy
6. Ipsilateral placement of the kidney & implantation to the common iliac vessels compared to contralateral iliac fossa placement & implantation to external iliac vessels was associated with a lower incidence of lymphocele (2.1% vs. 8.5%).
7. Maximum disruption of lymphatics.
8. Use of tacrolimus,
9. Adult polycystic kidney disease in the recipient
10. Obesity in the donor (BMI>30)
11. Immunosuppressive agents ( sirolimus, MMF and prednisolone combination. Sirolimus alone and ATG in induction.
12. LMW heparin after transplantation.
13. Increased recipient age
14. Increased warm ischaemia time
15. ATN and delayed graft function.
16. Prolonged pre-transplant dialysis.
17. Retransplantation.
18. acute rejection of the graft.
CLINICAL PRESENTATION
▪︎Asymptomatic or may exert pressure effects causing symptomatic presentation.
▪︎Impaired graft function, catastrophic renal artery or vein thrombosis, hydro ureter or hydronephrosis of the graft, unilateral limb oedema, scrotal or vulval oedema and DVT of the iliac veins.
▪︎Large lymphoceles may cause abdominal discomfort, pain, urgency and backache (sacral nerve compression).
▪︎When associated with wound dehiscence can lead to sepsis or lympho-cutaneous fistula.
DIAGNOSIS
1. USS can determine the collection as well as its dimensions, location in relation to the graft and possible effects on the graft vessels and ureter and the possible presence of infection.
2. USS guided aspiration, and analysis (creatinine, electrolytes, protein content, gram stain and culture) of contained fluid allows differentiation from urinary leak and urinoma.
3. CT can assist in differentiating innocuous lymphoceles from infected ones and other collections such as hematomas.
4. CK levels of the fluid to evaluate the origin of the lymph; donor or recipient (recipient origin demonstrating higher levels of CK).
TREATMENT
▪︎In the absence of any demonstrable pressure effects or evidence of infection, such lymphoceles can be safely left alone with periodic imaging surveillance.
▪︎The decision to intervene depends on definitive pressure effects causing symptoms, graft dysfunction, evidence of sepsis or fistula formation. ▪︎Percutaneous aspiration and sclerotherapy
▪︎ Symptomatic ones can be aspirated under USS
guidance and it can allow for sampling of the collection to establish its true nature and rule out infection. However, lymphocele would not be treated just by aspiration. ▪︎Some clinicians recommend:
1. Placement of a percutaneous drain to minimise reaccumulation
2. Sclerotherapy to sclerose open lymphatics.
▪︎Laparoscopic fenestration
▪︎ Large lymphoceles can be opened into the peritoneal cavity by making fenestrations in the lymphocele capsule.
Open surgery:
Is indicated when
1.There is infection or where laparoscopic fenestration is not possible.
2. The lymphoceles located in relation to the lower pole of the graft
3. There is complex lymphoceles causing vascular .
However, open drainage carries a significantly higher risk of ureteric damage.
CONCLUSION
▪︎ Peri-graft lymphocele is fairly common in renal transplant recipient. However, the vast majority of these remains asymptomatic and is self-limiting.
▪︎Close surveillance is required to rule out pressure effects and possible secondary infection.
▪︎Symptomatic or complicated lymphoceles require prompt intervention.
▪︎Small lymphoceles, only if there is clinical indication, may be treated with percutaneous techniques to allow resolution.
▪︎Recurrent collections or large volume lymphoceles are best treated by laparoscopic fenestration into the peritoneal cavity.
♧ Level of evidence: V
Lymphocele
Risk Factors:
Surgical Risk factors:
Non-Surgical Risk Factors:
Clinical Presentation:
Most of the lymphoceles are asymptomatic. Depending on the size and location in relation to the graft, lymphoceles may exert pressure effects.
Signs and symptoms include:
Diagnosis:
Treatment:
The level of evidence is V
Summary:
Introduction
Lymphocele is a post-transplant complication that occurs during the first 6 weeks and some may happen even earlier than 1-2 weeks. It is an abnormal collection of lymphatic fluid due to the seal of perivascular lymphatic channels incised during operation. Its incidence is about 0.6-34% and its mean incidence peak is about 5.2%, 6 weeks post-transplantation.
The risk factors that may contribute:
1) During surgery, the donor kidney, and hilar lymphatics may be damaged probably during the time of nephrectomy or maybe during the dissection.
2) The cause of the leak is if the lymphatic around the iliac vessel were ligated or clipped.
3) Regarding open nephrectomy and laparoscopic surgery, laparoscopy surgery has a higher incidence of lymphocele than open surgery.
4) Depending on the complexity of the arterial anatomy of the kidney.
5) Other risk factors not surgical are:
a) diabetic patients.
b) Obesity
c) ADPKD
d) Recipient’s age
e) ATN
f) Delayed graft function
g) Depending on the ischemic warm time
The clinical presentation:
It can be asymptomatic that is dependent on the size of the lymphocele. It can be small or large volumes. The small lymphocele may be asymptomatic but the backflow pressure can cause impaired graft function, can cause hydronephrosis, scrotal or vulval edema, deep vein thrombosis, etc.
The large volume can cause pain, abdominal pain, lumbar pain urinary urgency, etc. There can be signs and symptoms of infection and wound dehiscence.
Diagnosis:
The collections are based on the:
1) Ultrasound to detect
2) Fluid can be removed via ultrasound-guided and test for culture, creatinine, potassium, etc.
3) CT scan
Treatment:
A) Asymptomatic lymphoceles, sometimes small volumes, may not require intervention or specific treatment. It is left alone and monitored for signs of infection.
B) Large-volume ones can make percutaneous aspiration and sclerotherapy can be done. If the infection is present treatment must be given.
C) Re-intervention surgically can be done.
D) Laparoscopic fenestration
So in conclusion, lymphocele is a surgical complication of transplantation that depending on the volume may be treated conservatively or surgically.
The article’s level of evidence is level 5
# Please summarise this article
#The aim of this review:
To recognize the risk factors for lymphocele formation along with different management options and their outcomes.
# INTRODUCTION:
* A lymphocele is an abnormal accumulation of lymphatic fluid that lacks an epithelialized cover, usually occurring at a site where there is a massive surgical dissection.
*In renal transplantation, it is occur beside the graft, as a result of many factors including damage to recipient retroperitoneal lymphatics and donor lymphatics accompanying the allograft.
*Post transplant (PT) lymphocele rate shows a large variation ranging from 0.6% to 34%, and the peak incidence is a 6 weeks PT, but it can occur as early as 1-2 weeks and may occur several months to years PT.
# Pathophysiology and risk factors:
# Surgery related risk factors:
*When the hilar lymphatics damaged either at the time of nephrectomy or during ‘back-table’ dissection.
*If dissected lymphatics around iliac vessels are ligated or clipped, it would leak lymph.
*The presence of the allograft and associated inflammatory processes increase lymph flow from the renal hilum as well as from the lymphatics around iliac vessels, resulting in lymphocele formation.
* Laparoscopic donor nephrectomy has been implicated with a higher incidence of lymphocele compared to open nephrectomy.
*Complex arterial anatomy carried a higher risk of lymphocele compared to grafts with single renal artery.
*Ipsilateral placement of the kidney and implantation to the common iliac vessels compared to contralateral iliac fossa placement and implantation to external iliac vessels was associated with a lower incidence of lymphocele.
#Non-surgical risk factors
* Use of tacrolimus
*The incidence of acute rejection
* Diabetes in the recipient
*Adult polycystic kidney disease in the recipient
* Obesity in the donor (BMI>30)
*Use of sirolimus, mycophenolate and prednisolone combination.
*Use of rabbit anti-thymocyte globulin induction.
*Use of low molecular weight heparin after transplantation.
*Increased recipient age
*Increased warm ischaemia time
*Acute tubular necrosis and delayed graft function
*Prolonged pre-transplant dialysis
*Re-transplantation
#Clinical presentation
*The majority are asymptomatic
*Pressure on the hilar vessels can lead to:
Impaired graft function
Renal artery or vein thrombosis
It may goes undetected.
* Pressure on the ureter may lead to hydroureter or hydronephrosis of the graft.
* Pressure on the iliac vein or lymph drainage may lead to:
Unilateral limb oedema
Scrotal or vulval oedema
Deep vein thrombosis of the iliac veins.
*Large lymphoceles may cause abdominal discomfort, pain, urgency and backache.
*Sepsis, Lympho-cutaneous fistula and septic complications.
# Diagnosis
* USS (detect the collection, dimensions, relation to the graft, effects on the graft vessels and ureter).
* USS guided aspiration, and biochemical analysis of contained fluid (differentiate between the urinary leak and urinoma).
*Computerised tomography( differentiate lymphoceles from infected ones and other collections such as hematomas).
* Pacovsky et al. described higher levels of CK.
# Treatment
*The majority of asymptomatic are self-limiting and do not require specific treatment.
* In the absence of any demonstrable pressure effects or evidence of infection, it can be safely left alone with periodic imaging surveillance.
*The decision to intervene depends on definitive pressure effects causing symptoms, graft dysfunction, evidence of sepsis or fistula formation.
# Intra-operative drain placement
*The placement of retroperitoneal drains adjacent to the graft at the time of transplantation is a practice performed by many surgeons.
*These are usually removed once the drainage becomes negligible or before hospital discharge.
*Some studies have shown that drains placed intra-operatively decrease the incidence of lymphocele.
*It is remains an individual choice of the surgeon based on individual practice and patient characteristics.
# Percutaneous aspiration and sclerotherapy
*Symptomatic lymphoceles can be aspirated under USS guidance, it allows for sampling of the collection to establish its true nature and rule out infection.
* Percutaneous aspiration can, at the best, is a diagnostic step that helps in differentiation from urinoma.
*Some clinicians recommend placement of a percutaneous drain to minimise re-accumulation, but external drainage always get infected.
*The performing percutaneous drainage followed by sclerotherapy to sclerose open lymphatics with sclerosing agents have been described in various studies with varying degrees of success. These include; povidone iodine, fibrin glue, 95% ethanol, fibrinogen, sodium tetradecyl sulphate and tetracycline.
*The sclerosing agent has been instilled and kept in situ for varying periods ranging from 5 min to 24 h.
*There is a risk of introducing infection and direct graft injury and graft loss as a result of sclerosant installation.
# Laparoscopic fenestration
*Large lymphoceles can be opened into the peritoneal cavity by making fenestrations in the lymphocele capsule.
* Laparoscopic fenestration has shown high rates of success with a minimal rate of recurrence (4-8%).
# Open surgery
*Open surgical drainage of lymphocele is required in the presence of infection or where laparoscopic fenestration is not possible.
*Open drainage carries a significantly higher risk of ureteric damage and needs to be performed with the utmost care in order to minimize additional morbidity.
*The reported recurrence rate following open surgical drainage to the peritoneal cavity is 16% .
# What is the level of evidence provided by this article?
Level 5
Summary of the article
“Lymphocele after Renal Transplantation – A New Look at an Age-Old Problem!”
A lymphocele: is a lymphatic fluid collection without epithelial outline, and the reported incidence ranging from 0.6% to 34% post-transplant. The peak incidence of lymphoceles has been reported at 6 weeks post-transplant. However, it may occur as early as 1-2 weeks after transplant and may occur several months to years after transplantation.
Causes and pathophysiology of lymphocele:
A. Surgical risk factors:
1. Damage to host retroperitoneal lymphatics as well as donor lymphatics.
2. Donor kidneys with complex arterial anatomy carried a higher risk of lymphocele (12.5%).
3. The ipsilateral placement of the kidney and implantation to the common iliac vessels compared to contralateral iliac fossa placement and implantation to external iliac vessels was associated with a lower incidence of lymphocele.
4. Inflammatory processes increase lymph flow from the renal hilum as well as from the lymphatics around iliac vessels, resulting lymphocele formation due to lymph leakage.
B. Non-surgical risk factors
1. Goel et al., and many authors have independently described the acute rejection of the graft as an independent risk factor for the incidence of lymphocele.
2. Diabetes in the recipient proved to be an independent risk factor.
3. Adult polycystic kidney disease in the recipient has also been described as a potential risk factor.
4. Obesity in the donor (BMI>30) has also been described as an independent risk factor for the occurrence of lymphocele.
5. The correlation between the incidence of lymphocele and the use of different immunosuppressive agents is controversial;
· Goel et al. demonstrated a significantly higher incidence of lymphocele with the use of sirolimus, mycophenolate and prednisolone combination.
· Langer demonstrated that the use of sirolimus was an independent risk factor for lymphocele formation.
· Tondolo et al. failed to show any correlation based on different immunosuppressive agents including sirolimus.
· Benavides described the higher incidence of lymphocele with the use of rATG induction.
· Lundin et al. demonstrated a significantly higher incidence of lymphocele with the use of low molecular weight heparin after transplantation.
6. Other risk factors implicated with lymphoceles in different studies include:
· Increased recipient age.
· Increased warm ischaemia time.
· Acute tubular necrosis and delayed graft function.
· Prolonged pre-transplant dialysis.
· Re-transplantation.
Presentations of lymphocele:
A. Asymptomatic, as incidental finding.
B. Symptomatic:
1. Causing cause graft dysfunction
2. Pressure effect
3. Sepsis; Association with wound dehiscence can lead to sepsis or lympho-cutaneous fistula. It requires careful assessment to differentiate from urinary leakage.
Diagnosis of lymphocele:
1. USS can determine the collection as well as its dimensions, location in relation to the graft and possible effects on the graft vessels and ureter.
2. USS guided aspiration, and biochemical analysis of contained fluid allows differentiation from urinary leak and urinoma.
· The biochemical analysis should be done for creatinine, electrolytes, protein content, gram stain and culture.
· Higher level of creatine kinase (CK) of the fluid (the clinical utility of this analysis from a management perspective remains unproven).
· Comparison with simultaneous samples taken from serum and urine for creatinine and electrolytes often become invaluable in differentiating from urinoma.
Treatment
1. Asymptomatic lymphoceles are mostly self- limiting. Small and asymptomatic lymphocele can be safely left alone, if:
· No pressure effects(small lymphoceles located cephalad to the graft, away from the vasculature and ureter).
· No evidence of infection.
2. Intra-operative drain placement: Some studies have shown that drains placed intra- operatively decrease the incidence of lymphocele.
3. Percutaneous aspiration and sclerotherapy
· Aspiration under USS guidance; can be diagnostic and therapeutic.
· percutaneous drainage followed by sclerotherapy; but the chief drawbacks of repeated installation of sclerosants are the risk of introducing infection and graft loss(it is worthwhile that external drainage or sclersing therapy are not correct options).
4. Laparoscopic fenestration: this allows for lymph to be internally drained to the peritoneal cavity whereby the peritoneal lymphatics would drain it into thoracic duct. It’s associated with high rates of success with a minimal rate of recurrence(4-8%). Precautions for this intervention are:
· Patient is fit to undergo general anesthesia.
· No evidence of infection.
· No peritoneal adhesion.
· Technically reachable lymphocele and no adjacent abdominal viscus or vasculature.
· Lymphocele’s capsule shouldn’t be thick and impenetrable.
5. Open surgery; recurrence rate is 16% and ureteric injury is a high risk.
Open surgical drainage of lymphocele is required in the followings:
· The presence of infection.
· Laparoscopic fenestration is not possible.
· Complex lymphoceles causing vascular compromise.
· Lymphoceles located in relation to the lower pole of the graft.
What is the level of evidence provided by this article?
This is a narrative review article.
Level of evidence grade 5.
Lymphocele after Renal Transplantation: A New Look at an Age-Old Problem!
INTRODUCTION.
Lymphocele is lymph collection pre-graft after transplantation with peak incidence at 6 weeks post ktx, mainly due to seal of perivascular lymphatic channels incised during operation.
RISK FACTORS.
Surgical factors:
–During nephrectomy lead to dissection of lymphatics.
– Associated inflammatory processes.
– Laparoscopic donor nephrectomy more than open.
– kidneys with complex arterial anatomy.
Non-surgical risk factors.
– Use of tacrolimus & Sirolimus, the incidence of acute rejection and diabetes
-ADPKD, Obesity, association with drugs still debatable.
CLINICAL PRESENTATION.
Asymptomatic mainly and are detected as an incidental finding on imaging, manifestation depending on the size, extent and location in relation to the allograft, lymphoceles.
– Pressure on the hilar vessels can lead to impaired graft function
– Pressure on the ureter may lead to hydro ureter or hydronephrosis.
– Unilateral limb oedema, scrotal or vulval oedema and deep vein thrombosis of the iliac veins.
– Large lymphoceles may cause abdominal discomfort, pain, urgency (due to bladder compression), backache (sacral nerve compression) and wound dehiscence.
-Lastly may lead to sepsis.
DIAGNOSIS.
–Detect collection by USG.
-Aspiration guided by USG and biochemical analysis of contained fluid (creatinine, electrolytes, protein content, gram stain and culture).
TREATMENT.
–Conservative treatment with serial imaging is the rule for small lymphocele without compression.
– Percutaneous aspiration and sclerotherapy.
Placement of a percutaneous drain allows for continuous drainage as well as repeated instilling of sclerosants but sometimes is associated with infection.
Laparoscopic fenestration.
To open into the peritoneal cavity by making fenestrations in the lymphocele capsule but first ,infection should be excluded.
Open surgery.
With infected lymphocele with high risk of ureteric damage.
CONCLUSION.
Lymphocele is surgical complication post ktx, mainly treated by conservative management , large one with pressure manifestation is treated by laparoscopic fenestration with good result.
Level of evidence :V
A lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialized
cover, usually occurring at a site of extensive surgical dissection.
Incidence ranging:
0.6% to 34%.
The incidence of symptomatic lymphocele is much lower and has been reported at a
mean of 5.2% the peak incidence of lymphoceles at 6 weeks post-transplant.
PATHOPHYSIOLOGY AND RISK FACTORS:
Surgical or medical risk factors:
The surgical risk factors involving the donor and recipient operation.
Donor kidney, hilar lymphatics may be damaged either at the time of nephrectomy or
during dissection.
If the lymphatics around iliac vessels were ligated or clipped, it would leak lymph.
Laparoscopic donor nephrectomy has been implicated with a higher incidence of
lymphocele compared to open nephrectomy.
Complex arterial anatomy.
Ipsilateral placement of the kidney and implantation to the common iliac vessels
compared to contralateral iliac fossa placement and implantation to external iliac vessels
was associated with a lower incidence of lymphocele.
Non-surgical risk factors:
Drug implication is controversial, Use of tacrolimus, the incidence of acute rejection and
diabetes in the recipient were all found to be significant in univariate analysis.
Adult polycystic kidney.
Obesity.
Increased recipient age.
Increased warm ischemia time.
Acute tubular necrosis.
Delayed graft function.
Prolonged pre-transplant dialysis.
Retransplantation.
CLINICAL PRESENTATION:
Asymptomatic:
Detected as an incidental finding on imaging.
Symptomatic presentation:
Pressure effect:
On the hilar vessels can lead to impaired graft function.
Renal artery or vein thrombosis.
Pressure on the ureter:
Hydroureter or hydronephrosis of the graft.
Pressure on the recipient iliac vein or compression of lymph drainage may lead to
unilateral limb edema, scrotal or vulval edema and deep vein thrombosis of the iliac vein.
Bladder compression, urgency.
Pressure on abdomen, cause abdominal discomfort.
Sacral nerve compression), pain, and backache.
Pressure on wound, Association with wound dehiscence can lead to sepsis or lympho-
cutaneous fistula.
DIAGNOSIS:
USS for diagnosis, Complex echo pattern with internal debris within the collection is
more indicative of complicated infected lymphocele.
CT scan.
USS guided aspiration, and biochemical analysis of contained fluid allows differentiation
from urinary leak and urinoma.
The biochemical analysis, for creatinine, electrolytes, protein content, gram stain and
culture.
Comparison with simultaneous samples taken from serum and urine for creatinine and
electrolytes.
TREATMENT:
Asymptomatic lymphoceles are self-limiting and do not require specific treatment.
In the absence of any demonstrable pressure effects or evidence of infection, such
lymphoceles can be safely left alone with periodic imaging surveillance.
Intraoperatively drain decrease the incidence of lymphocele.
Percutaneous aspiration and sclerotherapy:
Symptomatic lymphoceles can be aspirated under USS guidance.
Laparoscopic fenestration:
Has shown high rates of success with a minimal rate of recurrence (4-8%).
Open surgery:
Surgical drainage of lymphocele is required in the presence of infection (external
drainage) or where laparoscopic fenestration is not possible.
CONCLUSION:
Peri-graft lymphocele is common. However, the vast majority of these remains
asymptomatic and is self-limiting.
Close surveillance is required to rule out pressure effects on the graft and possible
secondary infection.
Level of evidence V.
INTRODUCTION
This review evaluates the risk factors, management and outcomes of lymphocele formation post kidney transplantation. Lymphocele is a collection of lymphatic fluid which occurs at the extensive surgical dissection site. It lacks epithelialized cover.
Post renal transplant, lymphocele usually occurs adjacent to the graft mainly due to:
Clinical presentation
Mean incidence is 5.2%
Time to peak incidence is 6 weeks post transplant.
PATHOPHYSIOLOGY AND RISK FACTORS
Surgical risk factors
Non-surgical risk factors
CLINICAL PRESENTATION
DIAGNOSIS
TREATMENT
CONCLUSION
The article discusses the risk factors, pathogenesis and treatment options of lymphocele post renal transplant
Introduction:
A lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialized cover, usually occurring at the site of extensive surgical dissection. Post-transplant, a lymphocele may occur adjacent to the graft that may cause symptoms depending on the symptoms. It can occur due to damage of recipient retroperitoneal lymphatics or donor lymphatics accompanying the allograft. The reported incidence of lymphocele is variable as majority are asymptomatic and self resolving and will not be diagnosed. The reported incidence is between 0.6%-34%. The incidence of symptomatic lymphoceles is much lower with a mean reported incidence of 5.2%
Pathophysiology and Risk Factors:
The etiology of lymphocytes may be categorized broadly into medical and surgical factors.
Surgical Risk factors:
More common than non-surgical risk factors
Donor kidney procurement can lead to damage to the hilarity lymphatics which continue to leak lymph after reperfusion and can contribute to lymphocele formation.
If dissected lymphatics around the iliac vessels are ligated or clipped, it would leak lymph.
Laparoscopic donor nephrectomy also has been known to increase the incidence of lymphoceles
Sansalone et al demonstrated that ipsilateral placement of the kidney and implantation to the common iliac vessels compared to contralateral iliac fossa placement and implantation to external iliac vessels was associated with a lower incidence of lymphocele.
Non-Surgical Risk Factors:
In one study, use of tacrolimus, diabetes and acute rejection were found to increase the incidence of lymphoceles. However, during multivariate analysis, only diabetes in the recipient proved to be an independent risk factor.
ADPKD in the recipient has also been postulated to be a risk factor.
Acute rejection has also been described to be a risk factor for lymphocele formation
Clinical Presentation:
The majority of lymphoceles are asymptomatic. Depending on the size and location in relation to the graft, lymphoceles may exert pressure effects. Signs and symptoms include:
Diagnosis:
The primary modality of diagnosis is imaging
USS is the gold standard for diagnosing lymphoceles as it can be used both as a diagnostic and diagnostic modality. USS guided aspiration of the contents can help to differentiate from a urinary leak and urinoma.
Treatment:
The vast majority of lymphoceles are asymptomatic and self limiting and do not require treatment. In the absence of any pressure effects on USS, such lymphoceles can be monitored with serial USS
If the lympocele is large and causing pressure symptoms, graft dysfunction, sepsis or fistula formation, then it will require treatment.
The treatment options include:
Conclusion:
Lymphocele formation post-transplant is fairly common. The risk factors for lymphocele formation are surgical (most common) or non-surgical. Majority of the lymphoceles are asymptomatic and resolve spontaneously. The large lymphoceles that cause pressure symptoms and lead to graft dysfunction and will need treatment. The treatment options include percutaneous drainage, laparoscopic fenestration and open drainage
The level of evidence is V
INTRODUCTION
· lymphocele may occur due to multiple factors including: damage to host retroperitoneal lymphatics, and donor lymphatics accompanying the allograft
· The incidence of symptomatic lymphocele is much lower than asymptomatic incidence
· The peak incidence at 6 weeks post-transplant, but it may occur at 1W or several months to years
PATHOPHYSIOLOGY AND RISK FACTORS
·Surgery related risk factors:
1.damage to hilar lymphatics (at the time of nephrectomy or during ‘back-table’ dissection)
2. the presence of the allograft and associated inflammatory processes increase lymph flow from the renal hilum as well as from the lymphatics around iliac vessels
3. Laparoscopic donor nephrectomy
4. donor kidneys with complex arterial anatomy
·Non-surgical risk factors:
1. Diabetes in the recipient proved to be an independent risk factor
2. Adult polycystic kidney disease in the recipient
3. Obesity in the donor
4. Increased recipient age
5. Increased warm ischaemia time
6. Acute tubular necrosis and delayed graft function
7. Prolonged pre-transplant dialysis
8. Re-transplantation
CLINICAL PRESENTATION
·Most of lymphoceles are asymptomatic and are discovered accidently during imaging
·may cause pressure effects according to size, extension, and location
·Impaired graft function due to pressure on the hilar vessels
·Hydronephrosis due to pressure on the ureter
·Pressure on the recipient iliac vein or compression of lymph drainage may lead to unilateral limb oedema, scrotal or vulval oedema and deep vein thrombosis of the iliac veins
·Large lymphoceles may cause abdominal discomfort, pain, urgency and backache
·Association with wound dehiscence can lead to sepsis or lympho-cutaneous fistula
DIAGNOSIS
· USS can determine the collection and its dimensions, location, and possible effects on the graft vessels and ureter
· USS guided aspiration, and analysis of the fluid, differentiate it from urinary leak and urinoma
· Complex echo pattern with internal debris within the collection is suggestive of complicated infected lymphocele
· CT may differentiate safe lymphoceles from infected ones and hematomas
· Higher levels of CK in the fluid may suggest that recipient is the origin of lymphocele
TREATMENT
· Asymptomatic lymphoceles mostly self-limited
· Intervention indicated if there are pressure effects causing symptoms, graft dysfunction, evidence of sepsis or fistula formation
· Intra-operative drain placement is controversial
· Percutaneous aspiration: safe, diagnostic and therapeutic
· Repeated sclerotherapy effect is questionable
· Laparoscopic fenestration: high rates of success with a minimal rate of recurrence, low morbidity, low hospital stays, but infection should be excluded before.
· Open surgery: for infected lymphocele, or laparoscopic fenestration not possible, lower pole lymphocele or complex lymphoceles causing vascular compromise
CONCLUSION
· Lymphocele is common but mostly asymptomatic and self-limited
· close surveillance is required to rule out pressure effects on the graft and possible secondary infection
· Symptomatic or complicated lymphoceles require prompt intervention with minimal morbidity to the graft as well as the patient
· Recurrent or large lymphoceles are best treated by laparoscopic fenestration, and if not possible, open surgical de-roofing indicated
What is the level of evidence provided by this article?
Narrative review level 5
lymphocyte post kidney transplan
this is can happened in the early post operative up to 6 weeks with collection between the bladder and the graft kidney
can happen up to 34 % post RTX and it is asymptomatic in most of cases
large lympocele which is originated from kidney hilum can obstruct the kidney and need surgical intervention
· Diagnosis:
o US to detect site, size and extent of the swelling (anechoic).
o Biochemical analysis of the aspirated fluid for creatinine, electrolytes, protein content, gram stain and culture.
o Comparison with simultaneous samples taken from serum and urine for creatinine and electrolytes often become invaluable in differentiating from urinoma
o Diagnosis of infected collection by Complex echo pattern with internal debris within the collection (hyperechoic) or confirmed by CT.
o Recipient origin lymph may demonstrate higher levels of CK than that of donor origin.
usually lymphocyte of more than 500ml is usually need to be drained
Laparoscopic fenestration of lymphocele to be drained through peritoneal lymphatics into the thoracic duct. infection must be excluded before this procedure, it is indicated for large lymphocele. it has low risk of recurrence (4-8%).
· laproscopic approach is better than open surgical procedure to minimize handling and damage of ureters.
· open de-roofing (Open approach for lymphocele drainage to the peritoneal cavity) has recurrence rate of 16%
club 3, lymphocele post kidney transplantation
Summary
· Lymphocele means abnormal collection of lymphatic fluid that lacks an epithelialized cover, usually occurring at a site of extensive surgical dissection.
· The incidence varies between 0.6-34%, so it is a common complication however, mostly it is asymptomatic and accidently discovered in US.
· Peak incidence after 6 weeks from transplantation, however it can occur early in 1st 2 weeks, or late months or years after transplantation.
· large lymphocele and that related to the hilum can be presented with obstructive symptom, graft dysfunction and lower limb edema, in such cases, surgical treatment is necessary.
· Etiology and risk factors:
o Surgical: damage of kidney lymphatics during native nephrectomy or on the dissection on back table. diathermy does not stop leaking lymph vessels. laparoscopic native nephrectomy and kidneys with multiple or complex vasculature have higher risk.
o Medical issues:
§ Recipient risk factors: as old age, prolonged ischemia time, diabetes and ADPCKD as huge kidney will compress and impair lymphatic drainage, use of immunosuppressives as sirolimus and r ATG may be associated with risk of lymphocele, occurance of acute rejection episodes with inflammation induced lymphangectasia, use of LMWH post transplant.
§ Donor factors: as obesity
· Clinical presentation; depends on site, size and extent.
o Most of cases are asymptomatic, discovered accidently in US.
o large one compresses hilar vessels causing their thrombosis (presented with acute graft dysfunction) , compressing ureters causing hydrouretronephrosis. compressing iliac vessels causing DVT and unilateral limb and genital edema.
o Huge one compresses the bladder (urgency) and causes abdominal pain and discomfort.
· Diagnosis:
o US to detect site, size and extent of the swelling (anechoic).
o Biochemical analysis of the aspirated fluid for creatinine, electrolytes, protein content, gram stain and culture.
o Comparison with simultaneous samples taken from serum and urine for creatinine and electrolytes often become invaluable in differentiating from urinoma
o Diagnosis of infected collection by Complex echo pattern with internal debris within the collection (hyperechoic) or confirmed by CT.
o Recipient origin lymph may demonstrate higher levels of CK than that of donor origin.
· Management:
o Asymptomatic or small cephalic lymphocele (away from hilar compression) : (after exclusion of vascular or ureteric compression), just follow up US .
o Symptomatic one (>140 ml): causing compressive symptoms, as graft dysfunction, sepsis or fistula formation require definitive intervention. (0.04-14.6% of reported lymphoceles)
o US guided aspiration is best intervention , to allow also fluid analysis and differentiation from urinoma. Percutaneous drain to minimise reaccumulation, but has high risk of infection.
o Sclerotherapy after US guided aspiration as (povidone iodine, fibrin glue, 95% ethanol, fibrinogen, sodium tetradecyl sulphate and tetracycline) helps to sclerose open lymphatics.
o Repeated instilling of sclerosants may be needed, but it is associated with increased risk of nfections.
o Intraoperative placement of retroperitoneal drains adjacent to the graft may decrease the incidence of lymphocele, however, it is not the standard of care (individualized approach).
· Outcomes:
o The recurrence rate between 10-95% (mean 59%), compared to 50% with percutaneous drain placement.
o lymphocele >500 ml were unlikely to resolve with percutaneous aspiration, sclerotherapy or drain placement.
· Laparoscopic fenestration of lymphocele to be drained through peritoneal lymphatics into the thoracic duct. infection must be excluded before this procedure, it is indicated for large lymphocele. it has low risk of recurrence (4-8%).
· laproscopic approach is better than open surgical procedure to minimize handling and damage of ureters.
· open de-roofing (Open approach for lymphocele drainage to the peritoneal cavity) has recurrence rate of 16%
o indications:
§ Presence of infection for external drainage
§ Lower pole of the graft or complex lymphoceles causing vascular compromise
§ conversion from laposcopic to open may be indicated in technical difficulty, presence of peritoneal adhesions, thick, impenetrable capsule of the lymphocele and injury to abdominal viscus.
· Level of evidence: narrative review (level V)
I like your summary and analysis.
I agree it is level 5 evidence.
We, in Liverpool, have never used sclerosants for lymphocele or any other collection related to transplant.
Ajay
PATHOPHYSIOLOGY AND RISK FACTORS
Surgery related risk factors
the most common are the surgical risk factors involving the donor and recipient operation.
During donor kidney procurement, hilar lymphatics may be damaged either at the time of nephrectomy or during ‘back-table’ dissection.
have been implicated with a higher incidence
Non-surgical risk factors
were all found to be significant in univariate analysis.
However, during the multivariate analysis, only diabetes in the recipient proved to be an independent risk factor
The correlation between the incidence of lymphocele and the use of different immunosuppressive agents is controversial. ((((Sirolimus)))))
rabbit ATG induction.
LMWH after transplantation.
. . Other risk factors:
patients with symptomatic lymphoceles had a significantly higher incidence of acute rejection compared to those who had no lymphoceles (51% vs. 20%).
CLINICAL PRESENTATION
DIAGNOSIS
• USS can determine the collection , location , possible effects on the graft vessels and ureter
• it guided aspiration, and biochemical analysis of contained fluid allows differentiation from urinary leak and urinoma.
The biochemical analysis should be done for creatinine, electrolytes, protein content, gram stain and culture.
Complex echo pattern with internal debris within the collection and hyper-echoic appearance are more indicative of complicated infected lymphocele
imaging with CT can also assist in differentiating innocuous lymphoceles from infected ones and other collections such as hematomas.
TREATMENT
The vast majority are self limiting
In the absence of any demonstrable pressure effects or evidence of infection, such lymphoceles can be safely left alone with periodic imaging surveillance.
The decision to intervene depends on definitive pressure effects causing symptoms, graft dysfunction, evidence of sepsis or fistula formation.
lymphoceles requiring definitive intervention varies between 0.04-14.6%
1- Intra-operative drain placement
Some studies have shown that drains placed intraoperatively decrease the incidence of lymphocele. However, other authors have reported contrary outcomes where drain placement showed no benefit in reducing posttransplant lymphocele
2- Percutaneous aspiration and sclerotherapy
Symptomatic lymphoceles can be aspirated under USS guidance and remain the safest mode of intervention where needed.
It also allows for sampling of the collection to establish its true nature and rule out infection.
Seroma may not appear again, if aspiration is really indicated. However, lymphocele would not be treated just by aspiration.
Some clinicians recommend placement of a percutaneous drain to minimise reaccumulation, but external drainage always get infected.
percutaneous drainage followed by sclerotherapy,
but it is mentioned here only for condemnation.
simple aspiration alone was associated with a recurrence rate between 10-95% (mean 59%), compared to 50% with percutaneous drain placement.
Different sclerosing agents
povidone iodine, fibrin glue, 95% ethanol, fibrinogen, sodium tetradecyl sulphate and tetracycline
several case reports have reported direct graft injury and graft loss as a result of sclerosant installation
3- Laparoscopic fenestration
Large lymphoceles can be opened into the peritoneal cavity
In patients who are fit to undergo general anesthesia, this can be performed by laparoscopic fenestration.
However, the presence of infection in the lymphocele needs to be carefully excluded before this procedure.
4- Open surgery
is required in the presence of infection (external drainage) or where laparoscopic fenestration is not possible.
Lymphoceles located in relation to the lower pole of the graft or complex lymphoceles causing vascular compromise is best treated by open de-roofing.
However, open drainage carries a significantly higher risk of ureteric damage
Level V
Hi Dr Ghalia,
I like your summary and analysis.
I agree it is level 5 evidence.
We, in Liverpool, have never used sclerosants for lymphocele or any other collection related to transplant.
I could not understand the usage of small as well as larger bolt points.
Ajay
Please summarise this article
Post transplant lymphocele is multifactorial and the incidence is 0.6 to 34%. It is well recognised morbidity and can present as merely collections, graft dysfunction, vascular compromise or sepsis. Peak incidence is usually at week 6 post transplant.
Risk factors
Surgical Risk factors
Damage to lymphatics during hilar surgery or Bench surgery
Use of diathermy rather than ligation to divide lymphatics
Complex vascular anatomy requiring more dissection
Laparoscopic approach may be associated with higher incidence
Ipsilateral vs contra lateral implant
Medical Risk factors
Diabetes in recipient
High BMI
Compression effect of native polycystic kidneys.
Immune suppressive drugs use
Retransplant
Acute rejection
Anticoagulation
Presentation
It will depend upon size and loaction
there can be –
incidental diagnosis
There can pressure effect on ureter, hilar vessels, sacral nerves, illiac veins and pelvic lymphatics
Investigations
Ultrasound scan or CT scan
Fluid analysis for creatinine, culture electrolytes and proteins.
Better compare with serum samples
Treatment
Use of drain during surgery reduces risk
Small and asymptomatic lymphoceles can be left alone
Those producing compressive effects require treatment.
Options include-
Percutaneous aspiration and sclerotherapy
laparoscopic marsupialization
External drainage if infected
What is the level of evidence provided by this article?
Thank you
Post-transplant lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialized cover due to lymphatic disruption.
The reported incidence shows a wide variation ranging from 0.6% to 34%
The peak incidence is at 6 weeks post-transplant and may occur early as 1-2 weeks.
Risk factors:
Surgical-related risk;
Damage to donor kidney lymphatics, kidneys with complex arterial anatomy carried a higher risk; laparoscopic donor nephrectomy carries a higher risk compared to open approach and implantation site ipsilateral vs contralateral placement and the degree of lymphatic disruption during dissection.
Non-surgical risk factors
Diabetes in the recipient, Obesity in the donor (BMI>30), ADPKD in the recipient may compress IVC and impair the drainage. Increased recipient age, Increase WIT, ATN, DGF, prolonged pre-transplant dialysis, Re-transplantation, and the use of sirolimus, mycophenolate and prednisolone combination may increase the risk. The use of LMWH post-transplantation may impair the sealing of damaged lymphatics. Acute rejection is involved with increased lymphangiogenesis that is associated with lymphocele.
CLINICAL PRESENTATION
Depending on the size, extent and location.
The majority are asymptomatic and detected incidentally.
Symptomatic lymphocele may cause pressure symptoms depending on the site;
Pressure on the hilar vessels; graft dysfunction, RAT or RVT.
Pressure on the ureter; hydroureter or hydronephrosis.
Pressure on the iliac vein or lymph drainage: edema and DVT
Bladder compression, abdominal discomfort, pain, urgency
Sacral nerve compression backache
Association with wound dehiscence can lead to sepsis or lympho-cutaneous fistula.
DIAGNOSIS
-US; dimensions, location, pressure effects, echogenicity, and aspiration.
-Biochemical analysis of drained fluid (creatinine, electrolytes, protein content, gram stain and culture).
-Comparison with simultaneous serum samples to differentiate urinary leak and urinoma
TREATMENT
Intra-operative drain placement reduces the risk
The majority do not require specific treatment if there are no pressure symptoms or infection.
If symptomatic (pressure-causing symptoms, graft dysfunction, sepsis or fistula formation).
– Percutaneous aspiration sclerotherapy+/- percutaneous drain.
– laparoscopic fenestration into the peritoneal cavity; high rates of success with a minimal rate of recurrence
– Open surgical de-roofing; in the presence of infection (external drainage)
Level of evidence 5 narrative review.
Hi Dr Hadeel,
I like your summary and analysis.
I agree it is level 5 evidence.
Why is more common in recipients transplanted after laparoscopic donor nephrectomy?
Ajay
Summary
This review article published in 2019 by JRTs
lymphoceles is one of the surgical complications post-kidney transplantation resulting in a large accumulation of lymphatic fluid with extreme surgical dissections with prevalence in the range of 0.6-34% and for symptomatic lymphocele even lower than 0.6%, the majority are asymptomatic and self-limited while in less extent some lymphoceles like perinephric lymphoceles got complicated with pressure symptoms on the graft or urinary bladder and might be symptomatic, got infected so patients can present with acute graft dysfunction, sepsis that needs intervention by ultrasound-guided drainage or surgical sclerotherapy.
This review article addresses the risk factors for lymphoceles and the available treatment options.
Risk factors
Multiple surgical and medical factors related to the recipients and donors can lead to an increase in the risk of lymphoceles, usually occurring after 6 weeks but sometimes as early as 1-2 weeks post-surgery and sometimes months later up to 1 year
it’s more with laparoscopic donor nephrectomy compared to open nephrectomy
1. Excessive surgical dissection of the recipient’s retroperitoneal lymph, or lymphatic dissection around the iliac vessels
2. Donor hilar lymphatic damage, during organ mobilization
3. a donor with multiple vessels
4. Vascular anastomosis with external iliac has more risk of lymphoceles compared to the anastomosis with common iliac or internal iliac vessels, the minimal surgical manipulations by the skillful surgeon is the key for lower the risk of lymphoceles.
Nonsurgical risk factors for lymphoceles
1. few studies reported an increased risk of lymphoceles with the use of sirolimus or everolimus with diverse results also ATG as induction IS, anticoagulation with heparin
2. recipients with DM and APCKD and the donor with obesity are considered independent risk factors for lymphoceles
3. Retransplantion (access manipulations and adhesions)
4. Acute rejection due to increased inflammation and lymphatic leak
The clinical presentation of lymphoceles depends on the size, and the site, however, most are asymptomatic and can be incidentally found during routine imaging only symptomatic large perihilar lymphocele can cause pressure symptoms on the graft or UB or hilar vessels can be associated with morbidity including graft obstruction, vascular thrombosis, and infection
Usually, diagnosis by US which can assess the size of the collection the site, and the relation to the graft and hilar vessels and ureter
Signs suggestive of infected lymphoceles includes large septate collections with internal echoes which indicate debris and hyperechoic collection compared to hypo or anechoic clear collections however for the diagnosis the US-guided drainage of such collection and to be sent creatinine and potassium level in order to differentiate from urine leak and also gram stain and culture for infective collection
Some studies reported the use of CK level to differentiate the origin of lymphocele (donor-related vs recipient ) however this will not impact the management plan
Treatment options
1. Asymptomatic small lymphocele, keep it and likely will resolve spontaneously up on follow-up images.
2. Symptomatic complicated lymphoceles need US-guided drainage and depending on the collection size may keep in subcutaneous drainage
The recurrence rate depended on the size of the collection the bigger the collection the higher the rate of recurrence > 50s, so might need injection with sclerotic agents (might increase the risk of infection) and still associated with > 30% recurrence
Surgical fenestration by laparoscopic drainage of the lymphocele to the peritoneal cavity
Open surgery is rarely indicated in large infected lymphoceles with precaution for the risk of iatrogenic injury to the ureter and it’s associated with a lower rate of recurrence of < 14% compared to laparoscopic fenestration.
What is the level of evidence provided by this article?
Narrative review level 5 of evidence
HiDr Saja,
I like your summary and analysis.
I agree it is level 5 evidence.
Why is more common in recipients transplanted after laparoscopic donor nephrectomy?
Ajay
Summary:
Pathophysiology and risk factors:
Non-surgical risk factors
Clinical Presentation:
Diagnosis:
Treatment:
The placement of retroperitoneal drains adjacent to the graft at the time of transplantation is a practice performed by many surgeons.
These are usually removed once the drainage becomes negligible or before hospital discharge.
this practice remains an individual choice of the surgeon based on individual practice and patient characteristics.
Symptomatic lymphoceles can be aspirated under US guidance and it allows for sampling of the collection to establish its true nature and rule out infection.
Some clinicians recommend placement of a percutaneous drain to minimise re-accumulation, but external drainage always gets infected.
The percutaneous drainage can be followed by sclerotherapy to sclerose open lymphatics, different sclerosing agents have been described in various studies with varying degrees of success, like povidone iodine, fibrin glue, 95% ethanol, fibrinogen, sodium tetradecyl sulphate and tetracycline.
several case reports have reported direct graft injury and graft loss as a result of sclerosant installation.
Large lymphoceles can be opened into the peritoneal cavity by making fenestrations in the lymphocele capsule; this can be performed by laparoscopic fenestration.
the presence of infection in the lymphocele needs to be carefully excluded before this procedure.
Laparoscopic fenestration has shown high rates of success with a minimal rate of recurrence.
Open surgical drainage of lymphocele is required in the presence of infection or where laparoscopic fenestration is not possible.
Lymphoceles located in relation to the lower pole of the graft or complex lymphoceles causing vascular compromise is best treated by open de-roofing.
open drainage carries a significantly higher risk of ureteric damage and needs to be performed with the utmost care.
Level of Evidence:
Level 5 (review article).
Hi Dr Huda,
I like your summary and analysis.
I agree it is level 5 evidence.
Why is more common in recipients transplanted after laparoscopic donor nephrectomy?
Ajay
Thank you
because of more lymphatic disruption.
Please summarise this article
-A lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialized cover, usually occurring at a site of extensive surgical dissection.
-In renal transplantation, a lymphocele may occur adjacent to the graft, due to multiple factors including damage to host retroperitoneal lymphatics as well as donor lymphatics accompanying the allograft.
– The incidence is ranging from 0.6% to 34%.The peak incidence of lymphoceles has been reported at 6 weeks post-transplant.
PATHOPHYSIOLOGY AND RISK FACTORS
Surgery related risk factors
– The most common are the surgical risk factors involving the
donor and recipient operation.
-Laparoscopic donor nephrectomy has been implicated with a higher incidence of lymphocele compared to open nephrectomy. The donor kidneys with complex arterial anatomy carried a higher risk of lymphocele compared to grafts with single renal artery .
– The ipsilateral placement of the kidney and implantation to the common iliac vessels compared to contralateral iliac fossa placement and implantation to external iliac vessels was associated with a lower incidence of lymphocele .
Non-surgical risk factors
–Diabetes and adult polycystic kidney disease in the recipient proved to be an independent risk factors.
-Obesity in the donor (BMI>30) is independent risk factor for the occurrence of lymphocele .
-There is higher incidence of lymphocele with the use of sirolimus, mycophenolate and prednisolone combination and rabbit anti-thymocyte globulin induction..
– Higher incidence of lymphocele with the use of low molecular weight heparin after transplantation.
– The acute rejection of the graft is an independent risk factor for the incidence of lymphocele.
CLINICAL PRESENTATION
-The vast majority of lymphoceles are asymptomatic .
-Depending on the size, extent and location in relation to the allograft, lymphoceles may exert pressure effects causing symptomatic presentation.
DIAGNOSIS
-The primary modality in diagnosis is imaging. USS can determine the collection as well as its dimensions, location in relation to the graft and possible effects on the graft vessels and ureter .
-USS guided aspiration, and biochemical analysis of contained fluid allows differentiation from urinary leak and urinoma. The biochemical analysis should be done for creatinine, electrolytes, protein content, gram stain and culture. Comparison with simultaneous samples taken from serum and urine for creatinine and electrolytes often become invaluable in differentiating from urinoma.
TREATMENT
-The vast majority of asymptomatic lymphoceles are self-limiting and do not require specific treatment.
– The decision to intervene depends on definitive pressure effects causing symptoms, graft dysfunction, evidence of sepsis or fistula formation:
Intra-operative drain placement
The placement of retroperitoneal drains adjacent to the graft at the time of transplantation is a practice performed by many surgeons.
Percutaneous aspiration and sclerotherapy
Symptomatic lymphoceles can be aspirated under USS guidance and remain the safest mode of intervention where needed.
Laparoscopic fenestration
Large lymphoceles can be opened into the peritoneal cavity by making fenestrations in the lymphocele capsule. This allows for lymph to be internally drained to the peritoneal cavity whereby the peritoneal lymphatics would drain it into thoracic duct.
Open surgery
Open surgical drainage of lymphocele is required in the presence of infection (external drainage) or where laparoscopic fenestration is not possible (internal drainage to the peritoneum).
What is the level of evidence provided by this article?
Level 5
Hi Dr Reem,
I like your summary and analysis.
I agree it is level 5 evidence.
Why is more common in recipients transplanted after laparoscopic donor nephrectomy?
Ajay
Please summarise this article
Introduction:
Lymphocele is an abnormal lymphatic fluid collection due disrupted epithelized cover of lymphatics. It incidence ranges from 0.03%-26%. Usually occurs 6 weeks after kidney transplant (ranges from 2 weeks – years post transplant ).
Pathophysiology:
Surgical causes: damage to the hilar lymphatics while taking the donor’s kidney, inflammatory process after implanting the allograft will increase lymph flow, laparoscopic nephrectomy more at risk, dissection around the external iliac vessels, deceased donors , and complex arterial anatomy are at risk.
Non-surgical causes: use of ATG, tacrolimus, diabetic recipient, acute rejection, adult polycystic kidney disease in the recipient, delayed graft function, increase warm ischemia time, prolonged time on dialysis before transplant, and obesity.
Clinical presentations: usually asymptomatic, pressure symptoms- hydronephrosis, scrotal swelling , unilateral lower limb edema, and DVT.
Diagnosis: usually diagnosed by ultrasound after aspiration of fluid and send for creatinine, potassium, protein, gram stain, and culture, to differentiate from urine leak/urinoma.
CT can be used for diagnosis, differentiating innocuous lymphoceles from infected ones and hematomas.
Treatment:
Intra-operative drain placement.
Percutaneous aspiration and sclerotherapy- success rate depends on the amount of the collection.
Laparoscopic fenestration- safer and lower morbidity, and recurrence rate.
Open surgical drainage (deroofing) of lymphocele- carries higher risk of ureteric injury and morbidity.
Conclusion: Lymphocele is a major post transplantation, usually asymptomatic, diagnosed by USS guides aspiration and analysis of fluid, mostly self limited, sometimes treated by drainage or laparoscopic fenestration.
What is the level of evidence provided by this article?
Level of evidence V
Hi Dr Alshaikh,
I like your summary and analysis.
I agree it is level 5 evidence.We, in Liverpool, have never used sclerosants for lymphocele or any other collection related to transplant.
Ajay
INTRODUCTION
*A lymphocele is an abnormal collection of lymphatic fluid
that lacks an epithelialized cover, usually occurring at a site
of extensive surgical dissection.
*A peri-graft lymphocele is well-recognised morbidity
following renal transplantation and can manifest in a broad
spectrum of clinical presentations
*This can range from indolent collections that cause graft dysfunction, vascular compromise or sepsis.
*The peak incidence of lymphoceles has been reported at 6 weeks post-transplant Or as early as 1-2 weeks after transplant.
*The incidence of symptomatic lymphocele is much lower and has been reported at a mean of 5.2% (range 0.03-
26%)
PATHOPHYSIOLOGY AND RISK FACTORS
Surgery related risk factors
The most common are the surgical risk factors involving the
donor and recipient operation.
Laparoscopic donor nephrectomy has been implicated with a higher incidence of lymphocele compared to open nephrectomy.
Non-surgical risk factors
1- Diabetes in the recipient AND acute rejection of the graf are independent risk factors.
2- Adult polycystic kidney disease in the recipient
3-Obesity in the donor (BMI>30)
4- Immunosuppressive agents (sirolimus, mycophenolate and prednisolone combination)with the use of rabbit antithymocyte globulin induction.
5-Use of low molecular weight heparin after transplantation.
6- Other risk factors; increased recipient age, increased warm ischaemia time, acute tubular necrosis and delayed graft function, prolonged pre-transplant dialysis and retransplantation.
CLINICAL PRESENTATION
1- The vast majority of lymphoceles are asymptomatic and are detected as an incidental finding on imaging
2- Depending on the size, extent and location in relation to the allograft, lymphoceles may exert pressure effects causing symptomatic presentation.
-Pressure on the hilar vessels >> impaired graft function or
catastrophic renal artery or vein thrombosis in rare instances
-Pressure on the ureter>> hydroureter or hydronephrosis of the graft.
-Pressure on the recipient iliac vein or compression of lymph drainage >> unilateral limb oedema, scrotal or vulval oedema and deep vein thrombosis of the iliac veins.
3-Large lymphoceles may cause abdominal discomfort, pain, urgency (due to bladder compression) and backache (sacral nerve compression).
Association with wound dehiscence can lead to sepsis or lympho-cutaneous fistula
DIAGNOSIS
1- USS guided aspiration, and biochemical analysis of contained fluid allows differentiation from urinary leak and urinoma.
2-The biochemical analysis should be done for creatinine,
electrolytes, protein content, gram stain and culture, Comparison with simultaneous samples taken from serum
TREATMENT
*asymptomatic lymphoceles are selflimiting and do not require specific treatment
*The decision to intervene depends on definitive
pressure effects causing symptoms, graft dysfunction,
evidence of sepsis or fistula formation. It can be done though one of the folowing:
-Intra-operative drain placement
-Percutaneous aspiration and sclerotherapy (For Small
volume collections, only if there is clinical indication)
-Laparoscopic fenestration for Recurrent collections or large volume lymphoceles
-Open surgery.
Hi Dr Esraa,
I like your summary and analysis.
I agree it is level 5 evidence.We, in Liverpool, have never used sclerosants for lymphocele or any other collection related to transplant.
Ajay
● Post-transplant lymphocele incidence is 0.6-34%.
● it may occur as early as 1-2 weeks after transplant or several months to years after transplantation.
● lymphocele occur due to damage to host retroperitoneal lymphatics as well as donor lymphatics accompanying the allograft.
● Surgical risk factors :
** Damaged hilar lymphatics
** Laparoscopic donor nephrectomy
** donor complex arterial anatomy
** Kidney contralateral placement and implantation to external iliac vessels
● Non-surgical risk factors
** Recipiant diabetes
** Recipiant polycystic kidney disease
** Obesity in the donor (BMI>30)
** use of sirolimus, mycophenolate and prednisolone combination, rabbit anti-
thymocyte globulin induction , low molecular weight heparin after transplantation.
● Other risk factors
** increased recipient age
** increased warm ischaemia time
** acute tubular necrosis
** delayed graft function
** prolonged pre-transplant dialysis
** Re-transplantation [21].
** acute rejection of the graft as well as lymphoceles is a risk factor for acute rejection
● The vast majority of lymphoceles are asymptomatic and are detected as an incidental finding on imaging.
● Pressure on the hilar vessels can lead to impaired graft function and renal artery or vein thrombosis
● Pressure on the ureter may lead to hydroureter or hydronephrosis of the graft. ● Pressure on the recipient iliac vein or compression of lymph drainage may
lead to unilateral limb oedema, scrotal or vulval oedema and deep vein thrombosis of the iliac veins.
● abdominal discomfort, pain, urgency and unilateral limb oedema
● sepsis or lympho-cutaneous fistula.
● Sepsis
● USS guided aspiration, and biochemical analysis for creatinine, electrolytes, protein content, gram stain and culture.
● USS can also indicate infection
within the collection.
● TREATMENT
** In the absence of any pressure effects or evidence of infection no treatment
** Intra-operative drain placement
**Percutaneous aspiration and sclerotherapy
** simple aspiration alone associated with a recurrence rate 10-95% compared to 50% with percutaneous drain placement.
** Laparoscopic fenestration for Large lymphoceles into the peritoneal cavity then into thoracic duct.
** Open surgical drainage in case of infection (external drainage) or where
laparoscopic fenestration is not possible (internal drainage to the peritoneum).
● Level : 5
Hi Dr Huda,
I like your summary and analysis.
I agree it is level 5 evidence.We, in Liverpool, have never used sclerosants for lymphocele or any other collection related to transplant.
Ajay
This review looks at the risk factors for lymphocele formation along with different management options and their outcomes . A lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialized cover, usually occurring at a site of extensive surgical dissection. Post-transplant lymphocele has a reported incidence of 0.6-34%. The peak incidence of lymphoceles has been reported at 6 weeks post-transplant. However, it may occur as early as 1-2 weeks after transplant and may occur several months to years after transplantation.
– Surgery related risk factors :
During donor kidney procurement, hilar lymphatics may be damaged either at the time of nephrectomy or during ‘back-table’ dissection. Laparoscopic donor nephrectomy has been implicated with a higher incidence of lymphocele compared to open nephrectomy.
– Non-surgical risk factors :
DM , obesity , ADPKD , sirolimus use , increased recipient age, increased warm ischaemia time , acute tubular necrosis and delayed graft function , prolonged pre-transplant dialysis and retransplantation.
– CLINICAL PRESENTATION :
· majority of lymphoceles are asymptomatic and are detected as an incidental finding on imaging.
· Depending on the size, extent and location in relation to the allograft, lymphoceles may exert pressure effects causing symptomatic presentation.
· Pressure on the hilar vessels can lead to impaired graft function and may even lead to catastrophic renal artery or vein thrombosis in rare instances where it goes undetected.
· Pressure on the ureter may lead to hydroureter or hydronephrosis of the graft.
· Pressure on the recipient iliac vein or compression of lymph drainage may lead to unilateral limb oedema, scrotal or vulval oedema and deep vein thrombosis of the iliac veins.
· Large lymphoceles may cause abdominal discomfort, pain, urgency (due to bladder compression) and backache (sacral nerve compression).
· Association with wound dehiscence can lead to sepsis or lympho-cutaneous fistula. The latter presentation requires careful assessment to differentiate from urinary leakage and needs prompt intervention to prevent septic complications.
– Diagnosis :
Ultrasound showing the size, relation to the kidney & possibility of infection & US guided aspiration & analysis for creatinine , electrolytes , culture , gram stain & protein content , help to differentiate between urinoma & lymphocele .
– Treatment:
· majority of asymptomatic lymphoceles are self limiting and do not require specific treatment. In the absence of any demonstrable pressure effects or evidence of infection, such lymphoceles can be safely left alone with periodic imaging surveillance. Notably, small lymphoceles located cephalad to the graft, away from the vasculature and ureter are unlikely to cause pressure effects and rarely need intervention.
· The decision to intervene depends on definitive pressure effects causing symptoms, graft dysfunction, evidence of sepsis or fistula formation.
· Options are :
1-Intra-operative drain placement
2-Percutaneous aspiration and sclerotherapy
3-Laparoscopic fenestration
4-Open surgery
level 5
I like your summary and analysis.
I agree it is level 5 evidence.
Ajay
Summary of the article;
Introdauction;
Lymphocele is an abnormal collection of lymphatic fluid following surgery, due to in part to the damage of the host retroperitoneal lymphatics, and a donor lymphatics associated with the graft, it usually around the graft in kidney transplantation.
lymphocele ia a common complication following a kidney transplant, may be asymptomatic, discovered suddenly during graft follow up, or it may be symptomatic, causing graft compression, dysfunction or sepsis.
peak incidence reported 6 weeks following transplant, but it may occur as early as 1-2 weeks, or some times it occur as late as months to years.
Risk factors;
Surgical risk factors;
Non- surgical risk factor;
Clinical presentation;
Diagnosis;
Treatment;
Conclusion;
Peri graft lymphocele, is a common comorbidity post renal Tx.
Majority of lymphocele are asymptomatic, and required no intervention.
Symptomatic lymphocele, required intervention, ranging from aspiration, drainage, laparoscopic or open surgery in some conditions.
Review article , evidence ((V)).
Hi Dr Kamal
I like your summary and analysis.
I agree it is level 5 evidence.We, in Liverpool, have never used sclerosants for lymphocele or any other collection related to transplant.
Ajay
Introduction
Damage of the host retroperitoneal lymphatics and donor lymphatics accompanying the allograft can lead to formation of a lymphocele adjacent to the graft in renal transplantation.
It can present either as an incidental finding or can cause graft dysfunction, vascular compromise or sepsis.
It’s actual incidence is variable because it is usually asymptomatic,
The symptomatic lymphocele represents 5.2%.
It usually occurs 6 weeks post transplantation but it can occur earlier or later.
Surgery related risk factors
Include leakage from hilar lymphatics after reperfusion if injured during the time of nephrectomy or during ‘back-table’ dissection.
Or it can leak from dissected lymphatics around iliac vessels if ligated or clipped.
The allograft and the accompanied inflammatory processes increase lymph flow from the renal hilum leading to lymphocele formation .
Laparoscopic donor nephrectomy is more liable to lymphocele formation more than open nephrectomy.
Donor kidneys with complex arterial anatomy are more susceptible to lymphocele formation more than grafts with single renal artery.
Ipsilateral placement of the kidney and implantation to the common iliac vessels had lower incidence of lymphocele compared to contralateral iliac fossa placement and implantation to external iliac vessels .
The minimal the lymphatics are disrupted the lower the incidence.
Non surgical risk factors
A study by Ulrich showed that tacrolimus use , acute rejection incidence and diabetes are risk factors for lymphocele occurrence but diabetes was an independent risk factor as well as obesity.
Adult polycystic kidney can be a risk for lymphocele due to impaired lymphatic drainage caused by pressure of the polycystic kidney on the IVC.
Sirolimus, mycophenolate and prednisolone combination increases lymphocele incidence.
Other studies stated that sirolimus and r ATG each one solely can increase lymphocele incidence .
Others demonstrated that acute rejection can increase lymphocele incidence and vice versa.
Other risk factors included old recipient age, increased warm
ischaemia time , ATN and delayed graft function , prolonged pre-transplant dialysis and retransplantation.
Clinical picture
It varies from being asymptomatic ,incidentally discovered which is common and symptomatizing in the forum of pressure manifestations.
If it pressed on the hilar vessels ,graft dysfunction can occur or rarely renal artery or vein thrombosis.
Graft hydroureter or hydronephrosis can occur due to pressure on the ureter while compression on the recipient iliac vein or compression of lymph drainage may lead to unilateral limb oedema, scrotal or vulval oedema and deep vein thrombosis of the iliac veins.
Large lymphoceles may cause abdominal discomfort, pain, urgency and backache.
Wound dehiscence association can lead to sepsis or lympho-cutaneous fistula which necessitate rapid intervention.
Diagnosis
USS along with USS guided aspiration and biochemical analysis of the fluid for creatinine, electrolytes, protein content, gram stain and culture.
Hyperechoic lesions can be indicative of infected lymphocele.
CT can be needed for further differentiation.
Treatment
Usually lymphoceles donot require intervention ,only followed regularly .
Intervention will be needed if pressure or infection signs are detected leading to graft dysfunction , sepsis or fistula .
Intraoperative drain placement benefit in decreasing lymphocele risk is controversial .
Percutaneous aspiration and sclerotherapy
It allows sampling and analysis to differentiate lymphocele from urinoma.
Seromas may not reoccur if aspiration was indicated.
Some studies mentioned that percutaneous drainage and sclerotherapy can be useful but this is not confirmed.
Krol et stated that lymphoceles with big volume more than 500 ml and symptomatic ones are unlikely to be cured by percutaneous aspiration, sclerotherapy or drain placement.
There are different sclerosing materials used and left for variable time ranging from 5 min -24 h, Studies reported 31 % recurrence rate with it’s usage.
Installing the sclerosants can lead to infection when repeated as well as graft injury and loss.
Laparoscopic fenestration
Large non infected lymphoceles can be drained in the intraperitoneal cavity after fenestration through the thoracic duct.
It has good outcomes but some technical difficulties can lead to conversion to open surgery.
Open surgery
If the previous method not applicable or if the lymphocele is infected, open surgery will ne required.
Open de-roofing is used for lower pole and complex lymphoceles.
Open surgery must be carefully done as it can cause ureteric damage.
Conclusion
Perigraft lymphocele is nearly common ,it is mostly asymptomatic and self limited but needs follow up to notice any pressure effects or infection and promptly treated.
Multiple risk factors can lead to it’s occurrence.
Small sized ones can be percutaneously drained if indicated
Large sized ones can be manged by laparoscopic fenestration.
-level of evidence is 5
I like your summary and analysis.
I agree it is level 5 evidence.
Ajay
This article is a review article with Level of evidence 5
Definition: Lymphocele is an accumulation of lymphatic fluid lacking an epithelial covering.
Pathogenesis: Lymphoceles in kidney transplantation are caused by the destruction of lymphatics in both the donor and recipient as a result of extensive dissection or ligation. Damaged lymphatics, unlike vessels, cannot be sealed by diathermy and hence continue to leak after transplantation.
Incidence
Lymphocele can arise in 0.6-34% of transplant recipients between 1-2 weeks and months to years following transplantation.
Risk factors for lymphocele development
Causes can be surgical and nonsurgical.
Surgical causes: A higher incidence of lymphocele is associated with laparoscopic donor nephrectomy compared to open donor nephrectomy.
Contralateral kidney transplantation, such as transplanting the right kidney on the left side or the left kidney on the right side, is linked to venous compression by the artery.
Compared to anastomosis to the common iliac vessels, anastomosis to the external iliac vessels is associated with a fourfold increase in the risk of lymphocele. Multiple arteries are associated with a higher incidence of lymphocele compared to a single artery transplant. Extended duration of thermal ischemia is also recognized as a risk factor.
Non-surgical considerations are as follow:
-The incidence of lymphocele is greater in living donor kidney transplantation than in dead donor kidney transplantation.
-Older receiver age -Second or third transplant -Recipient PCKD, DM, or obesity with a BMI greater than 30 -DGF or acute graft malfunction, especially due to AR and ATN
-Long duration of dialysis before to transplantation -Use of sirolimus, high-dose steroids, and ATG -Use of LMWH, which may affect lymphatic sealing (week evidence)
Clinical presentation
Lymphocele is symptomless in the majority of cases but can present with pelvic or back ache. Graft malfunction due to urinary tract blockage or vascular compression in the presence of a large lymphocele. Urgency and frequency of urination if the urinary bladder is compressed. Secondary infection and formation of an abscess if not adequately treated.
Diagnosis
US is the primary noninvasive method for assessing the lymphocele’s location, size, and the possibility of secondary infection (hyper-echoic) or not (hypoechoic or anechoic)
CT without contrast is required for improved evaluation and exclusion of a hematoma.
Diagnostic aspiration with measurement of creatinine and potassium in the drained fluid; if it is comparable to the serum, the diagnosis is lymphocele; if it is significantly higher than the serum, the diagnosis is urinaoma; additionally, microscopy (RBCS, WBCs) and culture are required to rule out abscess transformation.
Treatment
Asymptomatic lymphocele require simply surveillance and follow-up. Symptomatic lymphocele requires treatment.
Some suggest removing an intraoperative drain when no or very little fluid is evacuated.
Therapeutic US-guided aspiration is related with a 90% recurrence rate, whereas catheter drainage is associated with a 50% recurrence rate; nevertheless, catheter drainage is associated with an increased risk of infection.
If recurrent, there are two treatment options: fenestration of the lymphocele capsule, which permits drainage of the collection into the peritoneal cavity (laparoscopic or open), or open surgical drainage (external or internal drainage), which carries a greater risk of ureteric injury.
I like your summary and analysis.
I agree it is level 5 evidence.
Ajay
Lymphocele is seen adjacent to graft kidney in 0.6 to 34% (symptomatic in 0.03% to 26%) of transplant recipients, with peak incidence at 6 weeks (seen within 1-2 weeks to months and years post-transplant).
Risk factors for lymphocele:
Surgical risk factors include damaged hilar lymphatics during donor nephrectomy, ligated or clipped lymphatics around iliac vessels, presence of inflammation, laparoscopic donor nephrectomy, donor kidney with complex arterial anatomy, contralateral iliac fossa placement and implantation to external iliac vessels.
Non-surgical risk factors include use of tacrolimus, acute rejection, diabetes in the recipient, ADPKD, obese (BMI>30) donor, use of sirolimus (alone or in combination with steroids and MMF), use of rabbit ATG, low molecular weight heparin, increased recipient age, prolonged pre-transplant dialysis vintage, re-transplantation, ATN, DGF, increased warm ischemia time.
Clinical presentation: Mostly asymptomatic, they are detected incidentally. Symptoms are due to pressure effects, which include graft dysfunction due to pressure on hilar vessels leading to thrombosis, hydroureter or hydronephrosis due to pressure on ureter, edema over scrotum/ vulva or lower limb due to pressure on lymphatics, abdominal discomfort, pain, urgency due to pressure on urinary bladder, or backache due to pressure on sacral nerve.
Diagnosis: It can be done by imaging (ultrasound) for assessing the location, dimensions and echogenicity of the collection, and aspiration of the fluid for biochemical analysis (creatinine, potassium, protein, gram stain and culture). CT scan can be used to differentiate uninfected lymphoceles from infected lymphoceles and hematomas.
Treatment: Majority asymptomatic are self-limiting. Intervention is required in presence of pressure symptoms, sepsis, fistula formation, or graft dysfunction. Laparoscopic fenestration is the treatment of choice with low recurrence rates of 4-8%. Other methods like aspiration, percutaneous drainage, sclerotherapy and open surgical drainage are not used due to high recurrence rates.
2. What is the level of evidence provided by this article?
Level of evidence: level 5 – Narrative review
Hi Dr Amit,
We, in Liverpool, have never used sclerosants for lymphocele or any other collection related to transplant.
Ajay
Definition;
—————————————
A lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialized cover, usually occurring at a site of extensive surgical dissection .
Surgery related risk factor.
————————————-
1-During donor kidney procurement, hilar lymphatics may be damaged either at the time of nephrectomy or during ‘back-table’ dissection.
2-If dissected lymphatics around iliac vessels are ligated or clipped, it would leak lymph.
3-The presence of the allograft and associated inflammatory processes increase lymph flow from the renal hilum as well as from the lymphatics around iliac vessels, resulting lymphocele formation due to lymph leakage.
4-Laparoscopic donor nephrectomy has been implicated with a higher incidence of lymphocele compared to open nephrectomy.
Non-surgical risk factors.
——————————————
1-Use of tacrolimus.
2-The incidence of acute rejection
3-Diabetes in the recipient
4-Adult polycystic kidney diseas.
5-Obesity in the donor (BMI>30)
CLINICAL PRESENTATION;
—————————————————————
The vast majority of lymphoceles are asymptomatic and are detected as an incidental finding on imaging.
Depending on the size, extent and location in relation to the allograft, lymphoceles may exert pressure effects causing symptomatic presentation.
1- Impaired graft function;
Pressure on the hilar vessels can lead to impaired graft function and may even lead to catastrophic renal artery or vein thrombosis in rare instances where it goes undetected.
2- Obstructive uropathy ;
Pressure on the ureter may lead to hydroureter or hydronephrosis of the graft.
3- limb oedema , scrotal or vulval oedema ;
Pressure on the recipient iliac vein or compression of lymph drainage may lead to unilateral limb oedema, scrotal or vulval oedema and deep vein thrombosis of the iliac veins.
4- Abdominal discomfort, pain ,urgency and backache ;
Large lymphoceles may cause abdominal discomfort, pain, urgency (due to bladder compression) and backache (sacral nerve compression).
5- Association with wound dehiscence can lead to sepsis or lympho-cutaneous fistula.
The latter presentation requires careful assessment to differentiate from urinary leakage and needs prompt intervention to prevent septic complications.
DIAGNOSIS;
—————————————-
1-USS can determine the collection as well as its dimensions, location in relation to the graft and possible effects on the graft vessels and ureter .
2- USS appearance can also indicate the possible presence of infection within the collection. Complex echo pattern with internal debris within the collection is more indicative of complicated infected lymphocele . An uncomplicated lymphocele appears hypoechoic or anechoic compared to the hyper-echoic appearance of an infected lymphocele.
2- USS guided aspiration, and biochemical analysis of contained fluid allows
differentiation from urinary leak and urinoma.
3- Imaging with computerised tomography can also assist in differentiating innocuous lymphoceles from infected ones and other collections such as hematomas.
4- The biochemical analysis should be done for creatinine, electrolytes, protein content, gram stain and culture. Comparison with simultaneous samples taken from serum and urine for creatinine and electrolytes often become invaluable in differentiating from urinoma.
TREATMENT;
——————————————
The decision to intervene depends on definitive pressure effects causing symptoms, graft dysfunction, evidence of sepsis or fistula formation. The reported incidence of lymphoceles requiring definitive intervention varies between 0.04-14.6%
1- Intra-operative drain placement
2- Percutaneous aspiration and sclerotherapy
3- Laparoscopic fenestration
4- Open surgery
1- Intra-operative drain placement;
——————————————————
These are usually removed once the drainage becomes negligible or before hospital discharge.
Some studies have shown that drains placed intra- operatively decrease the incidence of lymphocele . However, other authors have reported contrary outcomes where drain placement showed no benefit in reducing post- transplant lymphocele.
This practice remains an individual choice of the surgeon based on individual practice and patient characteristics.
2- Percutaneous aspiration and sclerotherapy;
—————————————————————-
Symptomatic lymphoceles can be aspirated under USS guidance .
The advantages ;
———————-
A-safe
B-It also allows for sampling of the collection to establish its true nature and rule out infection.
c-It helps in differentiation from urinoma.
The eventual success rate also depends on the size and volume of lymphoceles;
1- a volume >140 ml were symptomatic.
2- >500 ml were unlikely to resolve with percutaneous aspiration, sclerotherapy or drain placement.
It was reported that,simple aspiration alone was associated with a recurrence rate between 10-95% (mean 59%), compared to 50% with percutaneous drain placement.
Different sclerosing agents have been described in various studies with varying degrees of success.These include; povidone iodine, fibrin glue, 95% ethanol, fibrinogen, sodium tetradecyl sulphate and tetracycline .
The sclerosing agent has been instilled and kept in situ for varying periods ranging from 5 min to 24 h.
Placement of a percutaneous drain allows for continuous drainage as well as repeated instilling of sclerosants if needed. However, the chief drawbacks of repeated installation of sclerosants are the risk of introducing infection.
3- Laparoscopic fenestration;
——————————————–
Large lymphoceles can be opened into the peritoneal cavity by making fenestrations in the lymphocele capsule.
The presence of infection in the lymphocele needs to be carefully excluded before this procedure.
The indications for conversion included technical difficulty in reaching the lymphocele, peritoneal adhesions, thick, impenetrable lymphocele capsule and injury to abdominal viscus.
The advantages ;
————————
A-Laparoscopic fenestration has shown high rates of success with a minimal rate of recurrence (4-8%)
B-It carries lower procedure-related morbidity, and reduced overall hospital stay compared to open surgical drainage.
4-Open surgery;
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Open surgical drainage of lymphocele is required;
1- In the presence of infection (external drainage)
2-where laparoscopic fenestration is not possible (internal drainage to
the peritoneum).
3-Lymphoceles located in relation to the lower pole of the graft or complex lymphoceles causing vascular compromise.
The reported recurrence rate following open surgical drainage to the peritoneal cavity is 16%
The disadvantages ;
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A- higher risk of ureteric damage
B-needs to be performed with the utmost care in order to minimize additional morbidity.
What is the level of evidence provided by this article?
————————————————————————–
level v
Dear Dr Ishag,
Your headings and sub-headings should be in bold or underline. That will make it easy to read.
I agree it is level 5 evidence.
Ajay
INTRODUCTION
Ø A lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialized cover, usually occurring at a site of extensive surgical dissection.
Ø Post-transplant lymphocele has a reported incidence of 0.6-34%
PATHOPHYSIOLOGY AND RISK FACTORS
ü Surgery-related risk factors:
Common is the surgical risk factors involving the donor and recipient operation
Laparoscopic donor nephrectomy
donor kidneys with complex arterial anatomy
the ipsilateral placement of the kidney and implantation to the common iliac vessels, compared to contralateral iliac fossa placement and implantation to external iliac vessels, was associated with a lower incidence of lymphocele (2.1% vs. 8.5%)
ü Non-surgical risk factors:
Tacrolimus use
the use of sirolimus
rabbit anti-thymocyte globulin induction.
Diabetes malleus
Adult polycystic kidney disease
CLINICAL PRESENTATION:
Ø The majorities of such lymphoceles are asymptomatic and are incidental findings on routine imaging of the allograft.
Ø Large-volume lymphoceles and those concerning the graft hilum may exert pressure effects causing potential graft dysfunction.
Ø Local symptoms may develop if the venous or lymphatic outflow of the gonads or lower limb impinges. Such symptomatic lymphoceles require definitive treatment
Ø Large lymphoceles may cause abdominal discomfort, pain, urgency (due to bladder compression) and backache (sacral nerve compression).
DIAGNOSIS:
The primary modality in diagnosis is imaging. USS
The biochemical analysis should be done for creatinine, electrolytes, protein content, gram stain, and culture.
TREATMENT
Most asymptomatic lymphoceles are self-limiting and do not require specific treatment.
Without any demonstrable pressure effects or evidence of infection, such lymphoceles can be safely left alone with periodic imaging surveillance.
The reported incidence of lymphoceles requiring definitive intervention varies between 0.04-14.6%
Intra-operative drain placement: decrease the incidence of lymphocele
Percutaneous aspiration and sclerotherapy:
Symptomatic lymphoceles can be aspirated under USS guidance and remain the safest mode of intervention where needed
Laparoscopic fenestration
Large lymphoceles can be opened into the peritoneal cavity by fenestrations in the lymphocele capsule.
Open surgery
Open surgical drainage of lymphocele is required in the presence of infection (external drainage) or where laparoscopic fenestration is not possible (internal drainage to the peritoneum). However, in this era of laparoscopy, open drainage is only of historical importance.
CONCLUSION
Peri-graft lymphocele is a reasonably common morbidity following renal transplantation. However, the vast majority of these remain asymptomatic and are self-limiting
Symptomatic or complicated lymphoceles require prompt intervention with minimal morbidity to the graft and the patient.
HI Dr Allam,
You mention risk factors of lymphocele, ‘Laparoscopic donor nephrectomy
donor kidneys with complex arterial anatomy’.
Summary : Lymphocele after renal transplant
This study is about the risk of post transplant lymphocele and the different options to manage this condition safely and effectively.
Lymphocele is an abnormal collection of lymphatic fluid that lacks an epithelialize cover occurring in areas where extensive surgical dissection has been done. The lymphocele can be found near the graft.
Surgical risk factors
Medical risk factors
Clinical features
Diagnosis
Treatment
Level of evidence
This is a narrative review article. Level of evidence 5.
Hi Dr Nandita,
I could not understand the risk factor for development of lymphocele, ‘Contralateral iliac fossa placement of kidney and implantation to external iliac vessels has higher risk of lymphocele formation”.
We, in Liverpool, have never used sclerosants for lymphocele or any other collection related to transplant.
Ajay
Please summarise this article
INTRODUCTION
A lymphocele is an abnormal collection of lymphatic fluid and usually occurring at a site of extensive surgical dissection
The incidence of lymphocele is variable (0.6%-34%), and lower for symptomatic (mean of 5.2%)
The peak incidence is at 6 weeks post-transplant (may be as early as 1-2 weeks and may occur months-years after transplantation)
PATHOPHYSIOLOGY AND RISK FACTORS
Surgery related risk factors (most common)
Damage of hilar lymphatics (at the time of nephrectomy or during ‘back-table’ dissection) during procurement
Laparoscopic donor nephrectomy (compared to open nephrectomy)
Donor kidneys with complex arterial anatomy (compared to grafts with single renal artery)
Contralateral iliac fossa placement and implantation to external iliac vessels
Non-surgical risk factors
Use of tacrolimus, the incidence of acute rejection and DM in the recipient (the only independent risk factor is DM)
Recipient APKD (external pressure on the IVC by the polycystic kidney resulting in impaired lymphatic drainage from the allograft and iliac region)
Donor obesity (BMI>30)
Immunosuppressive agents (controversial): sirolimus and LMWH
Other risk factors: increased recipient age, increased warm ischaemia time, ATN and DGF, prolonged pre-transplant dialysis and re-transplantation
Acute rejection
CLINICAL PRESENTATION
Mostly asymptomatic (incidental finding on imaging)
Symptomatic: pressure on hilar vessels lead to impaired graft function and renal artery or vein thrombosis. Ureter pressure leads to hydroureter or hydronephrosis . Pressure on iliac vein or compression of lymph drainage may lead to unilateral limb oedema, scrotal or vulval oedema and DVT of the iliac veins
Large lymphoceles may cause abdominal discomfort, pain, urgency (due to bladder compression) and backache (sacral nerve compression)
Sepsis/lympho-cutaneous fistula
DIAGNOSIS
USS: hypoechoic or anechoic (infected lymphocele is hyper-echoic)
USS guided aspiration and biochemical analysis of contained fluid (creatinine, electrolytes, protein content, gram stain and culture) with simultaneous samples taken from serum and urine for creatinine
Complex echo pattern with internal debris within the collection is indicative of infected lymphocele (USS)
CT (differentiating lymphoceles from infected ones and other collections such as hematomas)
TREATMENT
Most asymptomatic lymphoceles are self- limiting and do not require specific treatment (only observation if no pressure symptoms or infection)
Intra-operative drain placement
Placement of retroperitoneal drains at the time of transplantation (individual choice of the surgeon
Percutaneous aspiration and sclerotherapy
External drainage always get infected. Simple aspiration (high recurrence)
Sclerotherapy with sclerosing agent (povidone iodine, fibrin glue, 95% ethanol, fibrinogen, sodium tetradecyl sulphate and tetracycline) is associated with high recurrence rate and risk of direct graft injury and graft loss
Laparoscopic fenestration
Large lymphoceles can be opened into the peritoneal cavity by making fenestrations in the lymphocele capsule (exclude infection before the operation)
Minimal rate of recurrence (4-8%)
Lower procedure-related morbidity and reduced overall hospital stay (compared to open surgical drainage)
Open surgery
In case of infection or where laparoscopic fenestration is not possible
Lymphoceles located in relation to the lower pole of the graft or complex lymphoceles causing vascular compromise is best treated by open de-roofing
CONCLUSION
Although the majority of lymphocele are asymptomatic and self-limiting, morbidity is high with the peri-graft lymphocele
Rule out pressure effects on the graft and possible secondary infection by close surveillance
Identify patients at a high risk of lymphocele (risk factors)
Symptomatic or complicated lymphoceles require intervention, whereas small volume collections if indicated may be treated with percutaneous techniques to allow resolution
Recurrent collections or large volume lymphoceles are best treated by laparoscopic fenestration into the peritoneal cavity
What is the level of evidence provided by this article?
Level 5
Dear Abdallah,
I like your analysis and summary. I agree it is level 5 evidence.
Ajay