Management of lymphatic fistulas after arterial reconstruction in the groin.

BACKGROUND: Since its original description in the British Medical Journal in 1978, the treatment of lymphatic fistulas in the groin remains contentious. Lymph leaks remain a common cause of morbidity in patients who have undergone groin dissection. The aim of this review was to examine the evidence for prevention and treatment of lymphatic fistulas after arterial surgery in the groin. METHODS: A systematic review of the English language literature was undertaken to determine the success of the various treatment options described. RESULTS: A comprehensive literature search identified 46 studies describing several treatment options for lymphatic fistulas. A qualitative synthesis of these studies was performed. There was no consensus definition of lymphatic fistula. Treatments reviewed were: conservative management; lymphatic ligation; vascularized muscle flaps; and negative pressure wound therapy (NPWT). Due to poor study quality and the paucity of data no one treatment could be identified as superior. CONCLUSIONS: There was no quantifiable cut-off for either the amount of lymphatic output or number of days postoperatively that leakage continued to help determine when conservative measures should be abandoned and surgical intervention undertaken. There is some evidence supporting use of vascularized muscle flaps to reduce the volume of lymphatic drainage and help prevent secondary graft infection. The use of NPWT is also promising, but must be weighed against the associated risk of anastomotic bleeding and requirement for additional inpatient stay.

The retroperitoneal approach to the abdominal aorta in the endovascular era.

The aim of this review was to assess the place of retroperitoneal (RP) aortic surgery for abdominal aortic aneurysms (AAAs) in the endovascular era and evaluate the evidence supporting it in preference to the more traditional transperitoneal approach. As endovascular graft technology improves, open aortic surgery is declining. AAAs unsuitable for endovascular aneurysm repair are, by definition, anatomically challenging. The RP approach is especially suited to anatomic challenges such as those posed by contemporary open AAA because it facilitates access to the suprarenal aorta. There is evidence that the RP approach reduces postoperative morbidity and length of stay compared with transperitoneal approaches. The evidence available indicates that the RP approach should be the first considered for any AAA unsuitable for endovascular aneurysm repair; however, the technique is more difficult to learn and less commonly practiced than the transperitoneal approach. Combined with a decrease in training hours in the United Kingdom, there is a real threat that the RP technique will only be performed by an ever-decreasing number of enthusiasts.