Lymphoceles are cavities filled with lymphatic fluid that occur after surgical interventions1. Lymphorrea is defined as the flow of lymph from lymphatic ducts that drains externally through persistent lymphocutaneous fistulas (FLC). The definition of FLC is not very well described in the literature. Giovannacci et al. 2 defined an FLC as the secretion outlet at a flow of 30 ml/day for more than 3 days after surgery or persistent discharge after the fifth postoperative day. FLC has been described 4 years after surgery with drains of 50 ml per day3.
Primary congenital lymph fistulas are quite rare. Invasive procedures, mostly vascular, abdominal, pelvic and cardiac, are more likely to cause secondary lymph fistulas. Persistent lymphocutaneous lymph fistulas carry a high risk of complication and infection of the wound resulting in prolonged hospitalization, delay in rehabilitation and an increase of costs associated with the treatment.
The incidence of lymphoceles and FLC is variable in the different studies published to date. It is estimated between 2% and 8% of all vascular and abdominal or pelvic procedures 4,5. There seems to be a higher rate in patients with comorbidities.
FLC management requires individualization. Initial conservative treatment should be established with immobilization, elevation and compression of the limb, if possible. Failure to this, different sclerosing drugs such as ethanol, tetracycline, iodine solution or bleomycin and other compounds such as yttrium-90 or rhenium-186 6,7,8 may be injected percutaneously. Rates of conservative management success vary among the authors. Twineet 9 published control rates with conservative management of 80–100%. Other authors report 82% after 3 weeks of conservative management10. However, there are authors who defend the early surgical reintervention, especially if the drainage rate is high, in wound infections or in the presence of foreign bodies. Surgical reintervention carries its own risks.
Radiation therapy (RT) for the management of benign diseases is usually performed with lower radiation dose than those used for malignant tumors11. There are different indications for the use of RT in the treatment of benign disorders. Some examples are chronic degenerative pain12, soft tissue conditions like Dupuytren's disease or Peyronie's disease13, keloids scars, Grave´s orbitopathy14 and lymphoceles or persistent FLC15. In complex and refractory cases, in addition to the measures described above, RT can be considered as a treatment for FLC. RT in these cases is believed to have an anti-inflammatory effect. In order to achieve this, low doses per fraction and total ionizing radiation have a anti-inflammatory effect by decreasing the discharge of cytokines in pro-inflammatory cells. This changes the permeability of the cell membranes in vascular cells, increasing reabsorption of lymph. In addition, fibroblasts differ in fibrocytes, which promote fibrosis, increase nitric oxide and locally decrease lymphatic flow16.
Doses of 1–2 Gy per fraction cause aseptic vasculitis in the endothelium that destroys vascular light. Recent studies have reported that even lower doses (0.3–0.5 Gy per fraction) could be effective in the lymphatic fistula treatment. The aim of this study is to analyze our results in the FLC treatment with RT and the rate of secondary complications.
The aim of this study is to analyze our results in the treatment of FLC with RT and the rate of secondary complications.