Chapter 52 - Lymphatic complications

Question 1

Causes of lymphatic insufficiency after bypass

Answer 1

1) increased production of interstitial fluid

2) transport capacity of lymphatic system reduced due to injury in surgery

Question 2

Treatment of post-op edema

Answer 2

1) elevation
2) bed rest
3) correct cardiac failure
4) compression
5) stockings

drugs don’t help

Question 3

Rate of lymphatic fistula

Answer 3

0.8-6.4%

Question 4

Management of lymphatic fistula

Answer 4

1) wound care
2) systemic antibiotic
3) bed rest + elevation
4) vac therapy

Question 5

Usual lymphatic leakage days to stop

Answer 5

7-12 days with conservative management

Question 6

Surgical management of lymphatic fistula

Answer 6

30-60 min pre-op inject 5 ml isosulfan blue (Lymphazurin) into 1st and 3rd interdigit space
compression pump to increase lymphatic and venous drainage
oversew blue dye leakage

injection of fibrin glue

Question 7

Lymphocele vs seroma

Answer 7

Lymphocele has well-localized connection with one or more lymphatic channels

shows up readily on lymphoscintigraphy

Question 8

Management of lymphocele

Answer 8

small = observe
large near graft = excise

isosulfan blue injection
ligate/oversew lymphatic pedicle
muscle flap coverage to form new lymphatic outflow drainage

Question 9

Retroperitoneal lymphocele after aortic recon rate

Answer 9

0.1%

often associated with groin lymphocele

Question 10

Lymphocele after donated kidney

Answer 10

0.6-18%

Question 11

Pre-op treating patient for identifying chyle

Answer 11

24 oz whipping cream 4 hour before surgery

Question 12

Location of cisterna chyle

Answer 12

sits behind aorta near SMA origin
L2 between IVC and Ao

50% do not have a well-defined one

Question 13

Percutaneous sclerotherapy for lymphocele

Answer 13

1) talcum
2) bleomycin
3) doxycycline
4) povidone-iodine
5) fibrin sealant
6) absolute alcohol

Question 14

Symptoms of chylous ascites

Answer 14

1) progressive abdominal pain
2) dyspnea
3) nausea
4) malnourishment
5) lymphopenia and anemia

Question 15

Mortality with chylous ascites after open aaa

Answer 15

17%

Question 16

Management of chylous ascites

Answer 16

1) medium chain TG diet - decrease chyle formation
2) complete bowel rest and TPN
3) paracentesis
4) peritoneovenous shunt - may cause sepsis
5) surgical correction

Question 17

Surgery for chylous ascites

Answer 17

ligate mesenteric and para-aortic lymphatic leakage

Question 18

Formation of the cisterna chyli

Answer 18

1) right and left lumbar

2) mesenteric lymphatic trunks

Question 19

Rate of chylothorax after cardiothoracic surgery

Answer 19

0.2-1%

Question 20

Chylous fluid in lab

Answer 20

1) creamy layer
2) no odor
3) specific gravity > 1.012
4) TG level > 1.24 mM

Question 21

Management of chylothorax

Answer 21

1) conservative with drain
2) open repair of chylous leak
3) pleurodesis
4) parietal pleurectomy
5) VATS

Question 22

Indication to do VATS in chylothorax

Answer 22

1) high output fistula > 1000 ml/24 hr

2) 200 ml/24 hr for > 1 week