How to cite this article: Aurelus PJ, Ortiz RC, Rendón-Macías ME, Ortega-Rodríguez MC, De la Cruz-Yañiz H, Yamamoto-Nagano A, Torres-Díaz JS. [Lymphocele surgical treatment in pediatric kidney transplantation]. Rev Med Inst Mex Seguro Soc. 2016;54(2):142-5.
Received: June 15th 2014
Accepted: September 1st 2015
Pierre Jean Aurelus,a Roberto Carlos Ortiz,a Mario Enrique Rendón-Macías,a Ma. C. Ortega-Rodríguez,a Hermilo de la Cruz-Yáñez,b Alfonso Yamamoto-Nagano,a José Salustiano Torres-Díaza
aServicio de Trasplantes
Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano Seguro Social, Ciudad de México, México
Communication with: Pierre Jean Aurelus
Background: In a retrospective study, we evaluated; frequency, clinical presentation and treatment of lymphocele in pediatric patients with kidney transplant.
Methods: Between January 2004 and January 2009, we had 242 kidney transplantations, 197 from living donors and 45 from cadaveric donors. The technique was the usual, and the implants of the ureteres were by the technique Ricard modified. The treatment of lymphocele was by percutaneous punction and laparoscopic intraperitoneal drainage.
Results: We diagnosed lymphocele in seven patients (2.9 % with an IC95 %: 0.6-5.2 %) one female and six males. All patients went trough percutaneous drainage. Six patients presented lymphocele recurrence at 48 to 72 hours after the drainage. Surgical laparoscopic intraperitoneal drainage was performed with success.
Conclusions: Our frequency of lymphocele is the same reported in other studies (6-18 %). The treatment by laparoscopic intraperitoneal window seems to be the most appropriate in pediatric patients.
Keywords: Peritoneal diseases; Laparoscopy; Lymphocele; Kidney transplantation; Pediatrics
The accumulation of lymphatic fluid around a transplanted kidney is known as lymphocele.1 The incidence of onset ranges from 0.6 to 18% and is higher in cases of kidney retransplantation.2,3 The clinical data, laboratory and imaging studies, as well as the presence of pain, fever, hypertension, increased volume in the area of the graft implantation, urinary retention, edema in the ipsilateral limb, and histochemical analysis of the collected fluid and hypoechoic image collection by ultrasonography around the graft help make the diagnosis. Its onset is usually after two weeks to six months, with a median of seven weeks following the kidney transplant3-5 (Figures 1 and 2). In general, a volume less than 140 ml lymph tends to be asymptomatic and can be handled by evacuating puncture, however with larger collections and more symptoms, management by puncture or surgical evacuation is still controversial. In some cases the lymphocele resolves spontaneously, especially in collections less than 100 mL (Figure 2).5,6
Figure 1 Lymphocele
Figure 2 Ultrasound of lymphocele
In this observational, retrospective, descriptive study, we present the result of management of seven pediatric patients with renal transplantation lymphocele, six of whom had to have drainage through a laparoscopic peritoneal window, a technique mostly performed in adults.
From January 2004 to January 2009, 242 kidney transplants were performed in children aged 5-17 years old in the Unidad de Trasplantes of the Hospital de Pediatría del Centro Médico Nacional Siglo XXI of IMSS in Mexico City. In 45 patients the graft was cadaveric and the remaining 197 had a living related donor.
The transplants were performed with the surgical technique of renal graft placement in the iliac fossa with blood vessels anastomosed to the iliac; the ureter was implanted into the bladder by Ricard technique modified by De La Cruz, which consists of a 1-cm fold of the distal portion of the ureter onto itself prior to implantation in the bladder. During the dissection, all lymphatic vessels were ligated and cauterized. Patients received a triple immunosuppression regime based on the combination of: corticosteroids, azathioprine, mycophenolate, cyclosporine, tacrolimus, and sirolimus. Graft ultrasound was done immediately after surgery then daily during the first seven days after transplantation, with control each month for the next six months. Later only in cases of suspected complications.
During follow-up the presence of lymphocele was monitored; when these were small (< 100 ml) no procedure was performed, only when the volume increased above 140 ml or when the patient reported symptoms were they drained. The indicated therapeutic approach was performed at first with drainage by percutaneous puncture and observation of the volumes in the following days. In cases where lymphocele reappeared, it was decided to drain them internally via laparoscopic peritoneal window (Figure 3). After the drainage, ultrasound monitoring was done each month. It was considered healed when there was no recurrence at six months after drainage.
Figure 3 Peritoneal window
Of the 242 kidney transplants performed, 15 patients (6.2%) presented collections around the graft and seven patients (2.9%; 95% CI: 0.6 to 5.2%) were diagnosed with lymphocele, appearing between 10 and 14 weeks (with a median of 12) after transplantation. Six patients (85.7%) were male and one (14.3%) female. The age of patients diagnosed with lymphocele ranged from 3 to 14 years with a median of 9 years. In six patients the grafts were from living related donors, and the other was from a cadaveric donor.
The clinical manifestations of post-transplant lymphocele were diverse, one patient with a volume less than 100 ml of lymph was asymptomatic, three children with volumes between 140-300 ml showed pain and hypertension, and the other three with volumes over 340 ml had fever and edema of the ipsilateral pelvic limb. Six patients (85.7%) showed increased serum creatinine above 20% of baseline. Four patients were given prednisone, tacrolimus, and mycophenolate, the rest got an immunosuppression regime of: prednisone, mycophenolate, and sirolimus. In all patients the accumulation of liquid was seen at the lower pole of the graft.
All patients underwent percutaneous drainage at diagnosis, however only one resolved favorably, who was the one with less than 100 ml volume. The other six reaccumulated lymph fluid around the implant between 48 to 72 hours after drainage. These patients required surgical drainage through a laparoscopic peritoneal window. There were no infectious or hemorrhagic complications or graft loss due to the procedure. Patients were discharged to their homes within 48 hours of the procedure. The monthly ultrasound control through six months showed no recurrence in any patient.
The incidence of lymphocele mentioned in the literature is between 0.6 to 20%. In particular, relapse is generally lower in grafts from living donors. In a study that evaluated 25 patients with these conditions, the authors reported an incidence of 4%,2,7-9 slightly higher than that found in our patients with 2.9%, although because of the sample size we cannot conclude that this reduction is statistically significant.
In a study of 528 patients, the emergence of lymphocele was found an average of 6 months after renal transplantation, with no difference between genders.2,9 In our study, the appearance of lymphocele was faster, as the median was around 12 weeks; this phenomenon may be due to the greater amount of lymphatic tissue in children. On the other hand, our highest incidence was found in males, unlike the absence of gender predominance in other studies. Due to our sample size it is difficult to conclude the effect of gender on this complication and we have no explanation for this difference.
The diagnosis of our patients was similar to that accepted in large studies. In a study of 2147 kidney transplants and 17 patients with lymphocele, eight of them showed elevated creatinine and abdominal pain with increased volume in the graft site at diagnosis, as happened in six of our patients.3,9 In this paper, the diagnosis was made by clinical signs, ultrasonography, and computerized tomography, in addition to the microscopic and histochemical analysis of fluid aspirated by needle.3,6,9 In our study, the clinical data found were pain, fever, edema at the limb, and increased creatinine. Like previous studies, diagnoses were suspected and performed by elevated creatinine, ultrasound, and finally histochemistry of aspirated fluid.
Some studies show that the most common site of lymphatic fluid accumulation is around the lower pole of the renal graft,9,10 as observed in our patients.
In multiple studies, percutaneous drainage is used as first measure with a very high recurrence rate (about 90%). Therefore, others chose washes with some medications such as tetracycline and povidone iodine. However, even with these maneuvers recurrence was high, reported from 11 to 90%. It is not uncommon that many patients end up undergoing internal open or closed drainage,3,8-10 which occurred in our study when we found a recurrence after 72 hours of 85.7%.
In this situation it was decided to perform drainage using the laparoscopic peritoneal window technique, previously performed in adults, but with little experience in children. This technique allows an approach with minimal trauma and low risk of complications, as happened in the management of our patients. Also, being a minimally invasive technique, it allowed a short hospital stay. The effectiveness of the procedure in our six patients was 100%, as during ultrasound monitoring no relapse or presence of any complications was shown.
The incidence of lymphocele in our pediatric kidney transplant patients is similar to that reported in the literature. Despite the low frequency of cases with symptomatic lymphocele, surgical management through a laparoscopic peritoneal window seems to be the most effective option in children.
Conflict of interest statement: The authors have completed and submitted the form translated into Spanish for the declaration of potential conflicts of interest of the International Committee of Medical Journal Editors, and none were reported in relation to this article.