INTRODUCTION
During cardiac operations, femoral vessels can be used to insert cannulas for cardiopulmonary bypass. However, surgical exposure of the common femoral vessels may be complicated by lymphatic leaks in the groin. The postoperative incidence of lymphatic leaks in the groin ranges from 4% to 6% of cases.1,2 The incidence is even higher for other operations; it may occur after 28% and 45% of arterial reconstructions and oncologic procedures, respectively, performed in the inguinal region.3,4
The leak is caused by a lesion to a lymph node or a lymphatic vessel. It consists of a protein-rich fluid that may contain bacteria from the genital and perianal regions. These leaks lengthen hospital stays and increase the risk of dehiscence and infection of the inguinal surgical wound. It can become a life-threatening complication if it causes an infection of prosthetic material sutured for the reconstruction of the femoral artery. Accordingly, prevention of this adverse effect cannot be overemphasized, including optimal surgical principles such as avoidance of the lymph nodes during the dissection and careful ligature of the severed lymphatic channels.
Lymphatic leaks can be difficult to manage and are often uncomfortable for the patient. Several therapeutic options are currently adopted to treat it. This report describes the nonoperative treatment of a recurrent lymphatic leak from an inguinal surgical wound via negative-pressure wound therapy (NPWT). The details of this case report and associated images are printed with patient consent.
CASE REPORT
A 19-year-old man was admitted to the authors' hospital for fever and was diagnosed with acute bacterial endocarditis involving the aortic valve. The causative microorganism was a methicillin-sensitive Staphylococcus aureus. The infection was complicated by multiple systemic embolisms involving the left inferior limb and by the formation of a perivalvular abscess with a fistula into the right atrium.
The patient underwent an emergency operation on cardiopulmonary bypass involving debridement of the infected tissue, patch closure of the right atrial fistula, and aortic root replacement with a composite mechanical valve graft. At the end of the procedure, the left femoral common artery was exposed because it was occluded by a large septic embolus that was removed. The groin incision was sutured using a layered closure over a Redon drain connected to a closed aspiration-collection reservoir.
The patient's early postoperative course was uneventful, with the exception of persisting fever. The healing of the groin wound was normal, and the Redon drain was maintained up to postoperative day 7 because of mild bloody discharge. Unfortunately, the patient remained febrile, and on postoperative day 16, a transesophageal echocardiogram revealed a significant left-to-right shunt secondary to an acquired septal communication between the left ventricle and the right atrium.
Accordingly, the patient underwent an emergency reoperation. The wound on the left groin was reopened; the deep layers showed signs of advanced healing without any fluid collection. The left common artery was cannulated for the arterial return from the heart-lung machine. Following debridement of the infected tissues, the atrioventricular septum was reconstructed by means of a patch, and the tricuspid valve and composite mechanical valve graft were replaced. The closure of the groin wound was performed in the same way as the first operation.
The early postoperative course was uneventful. However, the lymphatic liquid aspirated daily by the groin drain was large, ranging from 200 to 300 mL in 24 hours. Moreover, the serous liquid leaked through the subcutaneous tunnel of the drain, requiring multiple dressing changes every day.
Because lymphatic leak was refractory to local compression dressings, compression garments, and prolonged bed rest, 10 days following the cardiac reoperation, the patient underwent surgical re-exploration of the left groin wound and ligation of lymphatics. Subsequently, the amount of lymph collected by the drain decreased to 20 mL in 24 hours. The groin wound showed signs of regular healing, without secretion or swelling. However, the serous leak from the tunnel of the drain persisted, continuing to require multiple changes of the soaked dressings every day.
The groin drain was removed, and a tight compression dressing was reapplied, to no avail. It was believed that the likely source of lymph was inside the subcutaneous tunnel of the removed drain (Figure 1). Accordingly, providers decided to treat it with NPWT therapy (V.A.C.; KCI USA Inc, San Antonio, Texas). The intact skin was protected by a drape, and a 5-cm cylinder of polyurethane foam (Granufoam dressing; KCI USA Inc) was hand-shaped to fit inside the tunnel (Figure 2). The foam could not come in direct contact with the femoral vessels because of its length and the oblique course of the subcutaneous tunnel. The aspiration pad was put on a larger piece of foam.
Therapy was begun with -125 mm Hg of continuous pressure. Compressive dressings and bed rest were no longer required: the patient could ambulate immediately, and his motor rehabilitation course was restarted. During the first 24 hours of NPWT, 100 mL of lymph was aspirated by the device, and the leak progressively ceased during the next 24 hours. After 72 hours, the NPWT dressing was removed. The subcutaneous tunnel remained dry in the following days using normal wound dressings, and its closure occurred by second intention. The groin wound healed without incident. An echography revealed no lymphocele formation inside the wound 10 days after NPWT cessation.
DISCUSSION
Seroma and lymphatic leaks are common complications following the exposure of common femoral vessels for cardiac surgical procedures.1,2 Several techniques have been adopted to control lymphatic leaks after surgery, ranging from compression dressings to coverage with a musculocutaneous flap. In this report, a suction drain was placed inside the wound to prevent the formation of a seroma and promote tissue healing. This approach has been successfully used to treat postoperative lymphocutaneous fistulas of the groin in more than 80% of cases.5 However, it may require the drain to be maintained for some weeks.
Although published data are still very limited, NPWT has been successfully used to treat lymphorrhea following vascular surgical interventions on the groin.6,7 It has also been used also in combination with other techniques such as muscle flaps.8 Experimental studies show that NPWT prevents lymph stasis by compressing lymphatic vessels and reducing local edema.9 It may be indicated in open wounds to continuously remove fluids and exudate and promote local perfusion and formation of granulation tissue. However, its use is contraindicated if the wound contains a malignant neoplasm or undebrided necrotic eschar.
Further, the NPWT dressings must not be placed in direct contact with exposed cardiovascular structures and nerves. Vascular sutures and infected vessels are at particular risk of abrasion and rupture. Major bleeding from the groin has been reported in 7.1% of patients treated with NPWT because of wound complications following arterial reconstructive surgery.10 Accordingly, exposed vessels and nerves should be protected via coverage with native tissues or multiple layers of nonadherent dressings before the application of NPWT.
In this case, NPWT significantly decreased the lymphatic drainage after only 24 hours, stopping it after 48 hours. Besides its efficacy, it was much more comfortable for the patient because he was not restricted to bed (as he was when a compression dressing was used), and frequent changes of soaked dressings and bed sheets were no longer needed. More important, NPWT circumvented further surgical procedures to treat the lymphatic leak.
CONCLUSIONS
Negative pressure may be considered a minimally invasive, effective, and acceptable way to treat a postoperative lymphatic leak from the groin. In this case, its use mitigated the need for another surgical revision of the groin. Moreover, the authors believe that NPWT is advantageous for rehabilitation, allowing patients to continue walking and exercising after surgery. In contrast, groin compression restricts patients to bed. Further study is required to confirm this anecdotal result, and NPWT for lymphatic leaks of the groin should be compared with traditional therapies in terms of safety and efficacy in adequately powered studies.
REFERENCES