Percutaneous fractionated radiotherapy of the groin to eliminate lymphatic fistulas after vascular surgery.

BACKGROUND: Vascular surgery of the inguinal area can be complicated by persistent lymphatic fistulas. Rapid and effective treatment is essential to prevent infection, sepsis, bleeding, and possible leg amputation. Current data on irradiation of lymphatic fistulas lack recommendation on the appropriate individual and total dose, the time of irradiation, and the target volume. Presumably, a dose of 0.3-0.5 to 1-12 Gy should be sufficient for the purpose. Currently, radiotherapy is a "can" recommendation, with a level 4 low evidence and a grade C recommendation, according to the DEGRO S2 guidelines. As part of a pilot study, we analyzed the impact and limitations of low-dose radiation therapy in the treatment of inguinal lymphatic fistulas. PATIENTS AND METHODS: As a part of an internal quality control project, patients with lymphatic fistulas irradiated in the groin area after vascular surgery for arterial occlusive disease (AOD) III-IV, repair of pseudo aneurysm or lymph node dissection due to melanoma were selected, and an exploratory analysis on retrospectively collected data performed. RESULTS: Twelve patients (10 males and 2 females) aged 62.83 ± 12.14 years underwent open vascular reconstruction for stage II (n = 2), III (n = 1), and IV (n = 7) arterial occlusive disease (AOD), lymph node dissection for melanoma (n = 1) or repair of a pseudoaneurysm (n = 1). Surgical vascular access was obtained through the groin and was associated with a persistent lymphatic fistula, secreting more than 50 ml/day. Patients were irradiated five times a week up to a maximum of 10 fractions for the duration of the radiation period. Fraction of 0.4 Gy was applied in the first 7 cases, while 5 patients were treated with a de-escalating dose of 0.3 Gy. There was a resolution of the lymphatic fistula in every patient without higher grade complications. CONCLUSION: Low-dose irradiation of the groin is a treatment option for persistent lymphatic fistula after inguinal vascular surgery.

[Radiotherapeutic management of lymphatic fistulas : An effective but disregarded therapy option]. / Strahlentherapeutisches Management von Lymphfisteln : Eine effektive, aber wenig beachtete Therapieoption.

BACKGROUND: Lymphatic fistulas and lymphoceles are known complications after vascular surgery of the groin and after extended surgical interventions in the pelvic region. Unfortunately, conservative standard therapies are not always successful. OBJECTIVES: Evaluation of the therapeutic efficacy and related side effects of percutaneous low-dose irradiation in patients with lymphorrhea and definition of its importance. MATERIAL AND METHODS: Current presentation of previously published case series, reviews and guidelines. RESULTS: The use of low-dose irradiation therapy with single doses of 0.3-0.5 Gy leads to a cessation of the lymphatic flow in a high percentage of patients when standard therapies do not show a sufficient effect. With cessation of lymphorrhea irradiation should be terminated. Acute side effects have not been reported and the risk of tumor induction is almost negligible. CONCLUSION: Low-dose irradiation is an effective and very well-tolerated therapeutic alternative in the treatment of lymphatic fistulas and lymphorrhea when conservative therapies are unsuccessful.

Chyle Leak Following Neck Dissection: Could Radiotherapy Be Considered a Management Option?

Chyle leak after neck dissection is a relatively rare complication in head and neck cancer scenario.This review summarizes the basic knowledge of chyle leak underlying the potential benefit induced by low-dose radiation therapy and may serve as basis for future studies, necessary to optimize chyle leak management in head and neck cancer patients.

Pancreaticopleural fistula visualized by computed tomography scan combined with pancreatography.

CONTEXT: We report a case of a pancreaticopleural fistula which was clearly demonstrated by computed tomography (CT) scan following pancreatography and which was successfully treated with endoscopic nasopancreatic drainage combined with octreotide. CASE REPORT: A 52-year-old male was admitted to our hospital for additionally evaluation of bilateral pleural effusion. The pleural fluid amylase level was markedly elevated. Endoscopic retrograde pancreatography showed a cyst in the body of the pancreas and extravasation of contrast medium extending cranially from the cyst. The disease was treated successfully with endoscopic nasopancreatic drainage combined with the administration of octreotide. A pancreaticopleural fistulous route was clearly demonstrated by CT scan following pancreatography through the nasopancreatic drainage tube. CONCLUSIONS: A CT scan following pancreatography was useful in demonstrating a pancreaticopleural fistulous route.

[Radiotherapy of inguinal lymphorrhea after vascular surgery. A retrospective analysis]. / Die Strahlentherapie inguinaler Lymphfisteln nach gefässchirurgischen Eingriffen. Eine retrospektive Analyse.

BACKGROUND AND PURPOSE: The formation of inguinal lymphorrhea following vascular surgery is a rare but potentially serious problem with an incidence of about 2%. There is no consensus on the most effective treatment for groin lymphorrhea. In a retrospective analysis the usefulness of irradiation in the treatment of inguinal lymph fistulas was investigated. PATIENTS AND METHODS: From 08/1997 to 12/2000, 28 patients with inguinal lymph fistulas were irradiated postoperatively (4th-19th day) with a single dose of 3 Gy up to a total dose of 9 Gy on 3 consecutive days using 120- to 300-kV photons. Three further patients received 2 x 4 Gy and 3 x 5 Gy, respectively, due to an interposed weekend. RESULTS: Secretion volume at the beginning of radiotherapy varied between 50 and 650 ml daily (mean 203 ml, median 175 ml), at the end of radiotherapy between 0 and 350 ml (mean 126 ml, median 120 ml). 3/28 lymph fistulas had resolved during radiotherapy. In 17/28 patients (60.7%) the drains could be removed within 10 days, in further 10/28 patients (35.7%) within 10-20 days after the end of radiotherapy. CONCLUSION: Overall, irradiation of inguinal lymph fistulas proved to be an effective and well-tolerated treatment, facilitating removal of fistula drains within 10-20 days (mean 10.5, median 7 days) after the completion of radiotherapy, thus appearing a good alternative to other conservative treatment modalities.

Fístula carotidocutánea secundaria a radioterapia cervical / Carotid-cutaneous fistula secondary to cervical radiotherapy

Introducción. El tratamiento de muchos tumores de cabeza y cuello incluye una cirugía radical del área implicada seguida-' de radioterapia. En este contexto, la aparición de una ruptura espontánea de la arteria carótida es una complicación infrecuente, pero de una morbimortalidad elevada. Caso clínico. Un varón de 35 años acudió a revisión describiendo la aparición de un sangrado intermitente y abundante, a partir de una úlcera cutánea preexistente en la zona laterocervical izquierda. Había sido intervenido de un carcinoma epidermoide de la cavidad oral hacía 12 años, tras lo cual se le administró radioterapia local. Mediante una tomografia computarizada y una angiorresonancia se detectó un estrecho contacto del fondo de la úlcera con el bulbo carotídeo izquierdo. Ante la sospecha clínica de una posible fistula entre el eje arterial y el orificio cutáneo, se intervino en colaboración con el Servicio de Cirugía Maxilofacial, que realizó la cirugía primaria. Se realizó un abordaje posterior de la arteria carótida, comenzando por el control proximal y distal del eje carotídeo. Al resecar la zona ulcerada se produjo un sangrado profuso que obligó al pinzamiento temporal, mientras se reparaba la lesión mediante una sutura directa sobre el bulbo carotideo. Tras restablecer la continuidad vascular, se cubrió el defecto cutáneo con un colgajo con rotación amplia pectoral. El postoperatorio transcurrió sin incidencias, sin que se evidenciara ningún déficit neurológico central ni periférico. El estudio anatomopatológico descartó la recidiva tumoral. Conclusión. Las lesiones carotídeas asociadas a tumores del área orofaríngea constituyen una importante amenaza para la vida del paciente. La reparación quirúrgica electiva junto con un completo estudio de imagen permite disminuir la alta morbimortalidad de este tipo de intervenciones (AU)

[Radiotherapy of lymphatic fistula and lymphocele]. / Strahlentherapie von Lymphfisteln und Lymphozelen.

BACKGROUND: The treatment of persistent postoperative lymphatic fistulas or lymphoceles is often a problem. Approximately 2% of patients will develop lymphatic fistula after vascular surgery. This can require a long lasting conservative therapy. If spontaneous cure fails, a second operation with wound revision becomes necessary. We studied low-dose percutaneous radiotherapy to be used as an alternative treatment in addition to conservative or surgical therapy. PATIENTS AND METHODS: Between 1989 and 1998 29 patients (25 with lymphatic fistulas, 4 with lymphoceles) received radiation therapy. Depending on the depth of the fistula 27 patients were treated with electrons (7 to 18 MeV). Two other patients suffering of retroperitoneal lymphoceles received a treatment with photons (15 MV). In all patients the fractionation was 4- to 5 x 1.0 Gy/week and the dose ranged from 3 to 12 Gy depending upon the onset of the radiation therapy effect. RESULTS: In 27 of 28 evaluable patients a complete disappearance of the fistula or lymphocele was achieved by radiation during therapy or shortly afterwards. In 1 case no benefit was observed after a dose of 11 Gy. This patient required further surgery with wound exploration. CONCLUSION: Low dose percutaneous radiotherapy (up to 10 to 12 Gy) is effective to heal lymphatic fistulas and lymphoceles without complications. Individual dosage is required because doses even lower than 10 Gy may be effective. Radiation can be effective even after a failed conservative therapy or instead of surgery.

Small cell carcinoma of the esophagus with an esophago-mediastinal fistula successfully treated by chemoradiation therapy and intubation: a case report.

A case of esophageal small cell carcinoma with cervical node metastases and an esophago-mediastinal fistula was treated successfully by chemoradiotherapy. The fistula, after irradiation, was handled successfully by esophageal intubation, followed by infusional 5-fluorouracil and cisplatinum chemotherapy, resulting in the closure of the fistula. Two courses of concurrent chemoradiotherapy, followed by additional cisplatinum and etoposide chemotherapy, were administered. The tumor, including the cervical lymph node metastases, disappeared completely after the treatment.