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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3645_Библиотеки_им_академика_М_И_Перельмана
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Case 96
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History
▶ A34-Year-Old Male Status Post Motor Vehicle Accident with Le igh Swelling
A drain was placed percutaneously in the collection noted in Figure 96.1. e drain remained for 2 weeks with
persistent 30–40 cc daily serous-milky output. Figure 96.2 demonstrates a contrast study through the indwelling
drain. What are the treatment options?
Figure 96.1
Figure 96.2
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Case 96 Sclerosis of Traumatic Lymphocele
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Figure 96.3
Figure 96.4
Figure 96.5
Findings
▶ Alow-density uid collection in the so tissues of the lateral thigh (Fig. 96.3, white arrow).
▶ Contrast injection 2 weeks aer initial drain placement (Fig. 96.4) was performed because of persistent
outputs to determine cavity size (arrow). Atotal of 30 cc of contrast was required to completely opacify the
cavity.
▶ Aer 2 weeks of daily povodine iodine sclerosis, there is near-complete resolution of the collection (Fig. 96.5,
arrow). Only 2 cc of contrast could be injected prior to leakage out the drain tract. e drain was removed.
▶ CT was performed 1 week aer drain removal, showing complete resolution of the collection (Fig. 96.6, white
arrow).
Figure 96.6
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Teaching Points
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▶ Most lymphoceles are iatrogenic, related to pelvic or retroperitoneal surgery.
▶ ere are various treatment options available to treat lymphoceles with persistent ranging from surgical
marsupialization to catheter drainage to sclerotherapy.
▶ Many lymphoceles can be treated conservatively with spontaneous resolution.
▶ Lymphoceles can result in symptoms ranging from abdominal pain to urinary symptoms or constipation if
they compresses on the urinary bladder or bowel, respectively. If compressing on venous structures, patients
can also present with deep venous thrombosis.
Management
▶ Initial management may be aspiration or transcatheter drainage.
▶ Multiple sclerosants have been used for this purpose, the most common agents include ethanol, povidone
iodine, doxycycline, and bleomycin with varying success. Local preferences apply. is author trials use of
povidone iodine for 2–4 weeks, instructing the patient to inject the same volume as cavity size daily with
a 1 hour dwell time for cavities up to 50 cc. Doxycycline, ethanol, or bleomycin may be useful for treating
lymphoceles resistant to povidone iodine sclerosis.
Further Reading
Alago W, Deodhar A, Michell H, etal. Management of postoperative lymphoceles aer lymphadenectomy:percutaneous
catheter drainage with and without povidone-iodine sclerotherapy. Cardiovasc Intervent Radiol. 2013; 36:466–471.
Mahrer A, Ramchandani P, Trerotola SO, etal. Sclerotherapy in the management of postoperative lymphocele. J Vasc Interv
Radiol. 2010; 21:1050–1053.
290
Case 97
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History
▶ A65-Year-Old Female with Gastric Cancer Who Developed an Anterior Abdominal Collection aer Partial
Gastrectomy Is Transferred to Your Care aer Drainage with Persistent High Outputs
Figure 97.1
Figure 97.3
Figure 97.2
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Case 97 Small-Bowel Fistula
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Figure 97.4 Figure 97.5
Figure 97.6
Findings
▶ Adrainage catheter is seen in the anterior abdomen (Fig. 97.1). e collection that was drained (not shown)
has near completely resolved.
▶ Contrast injection into the indwelling drainage catheter (Fig. 97.4) demonstrates a near completely resolved
collection with a small sinus tract extending laterally (white arrow).
▶ Alater image from the contrast injection (Fig. 97.5) shows increased lling of the structure now recognizable
as duodenum (black arrow).
▶ Aer bowel rest and expectant management, the drainage decreased over 1month and follow-up contrast
injection (Fig. 97.6) demonstrates resolution of the stulous tract.
Teaching Points
▶ Persistently high outputs from a drainage catheter should raise the suspicion for a stulous connection to
bowel.
292
▶ Intermittent drain studies have been shown to decrease the overall catheter dwell time by ensuring optimal
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position of the catheter in the residual cavity and identifying stulae. Lastly, intermittent evaluation ensures
that the drainage catheter has not eroded into the stula tract and is providing optimal drainage of the
collection.
Management
▶ Depending on output of stula, measures such as uid repletion, proximal bowel diversion, or parenteral
nutrition may be necessary.
▶ Even in the presence of a persistent stula, if the output of the catheter is <10 cc, there is no residual abscess
cavity, and there is no downstream bowel obstruction, removal of the catheter should be considered.
▶ In some cases, exchange for a straight catheter that can be slowly backed out aer every weekly visit may be
helpful in allowing the stula to close.
Further Reading
Gervais DA, Ho CH, O’Neill MJ, etal. Recurrent abdominal and pelvic abscesses:incidence, results of repeated percutaneous
drainage, and underlying causes in 956 drainages. Am J Roentgenol. 2004; 182:463–466.
293
History
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▶ Ovarian Cancer and Recurrent Right Pleural Eusion Associated with Dyspnea
What is the best treatment option?
Figure 98.1
Case 98
Figure 98.2
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Case 98 Tunneled Pleural Catheter
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Figure 98.3
Figure 98.4
Findings
▶ Axial (Fig. 98.1) and coronal (Fig. 98.2) computed tomography (CT) images show a simple right pleural
eusion with associated compressive atelectasis of the right lower lobe (arrows, Fig. 98.3).
▶ Aer placement of a tunneled pleural catheter, there is decrease in the size of the eusion (Fig. 98.4). Note
the catheter is placed at the lung base, in the dependent portion of the hemithorax and courses medially
parallel to the spine in the right hemithorax. is course conrms that the catheter is placed posteriorly, in the
dependent part of the hemithorax, and not in the ssure, which would provide suboptimal drainage.
Teaching Points
▶ Tunneled pleural catheters are indicated in malignant and refractory pleural eusions. e catheters have a
valve to prevent air from entering the pleural space. is is important because negative intrathoracic pressure
is generated with every inspiration, and without a valve air could enter and accumulated in the pleural space
preventing lung expansion and impeding pleurodesis.
▶ Prior to tunneled pleural catheters, malignant pleural eusions were managed with chest tube placement
followed by chemical pleurodesis. is was associated with a prolonged hosptial stay and risks ranging from
pain to acute respiratory distress syndrome. In addition, unsuccessful chemical pleurodesis can turn a simple
eusion into a complex, multiloculated eusion that is more dicult to treat.
▶ Another advantage of tunneled pleural catheters is that they can be placed as an outpatient procedure and
obviate the need for hospitalization. Mechanical pleurodesis following tunneled catheter placement occurs
in 50%–60% of patients at a median of 4 weeks aer placement and probably results from physiologic
inammation of the visceral pleura caused by the catheter.
▶ In 2013, the FDA approved tunneled pleural catheters include the Pleurx © (Denver Biomedical) and the
Aspira© (CR Bard) catheters.
Management
▶ Drainage is performed by the patient or the patient’s care partner using specially designed vacuum bottles
(Pleurx) or drainage bags (Aspira). Drainage of up to 1 liter every other day is recommended.
▶ When output is <50 cc for three consecutive drainages (over approximately 1 week), repeat chest x-ray is
performed. If there is no signicant residual, the catheter may be removed.
▶ Alternatively, if there is residual eusion and low output from the catheter, alteplase and/or DNAase can be
instilled to disrupt loculations and improve drainage.
Further Reading
Myers R, Michaud G. Tunneled pleural catheters:an update for 2013. Clin Chest Med. 2013; 34(1):73–80.
295
Case 99
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History
▶ A67-Year-Old Male 2 Weeks Status Post Distal Esophagectomy and Partial Gastrectomy with New Fevers and
Leukocytosis
e following studies were performed for workup.
Figure 99.1
Figure 99.2
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Case 99 Anastomotic Leak
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Figure 99.3
Figure 99.4
Figure 99.5
Findings
▶ Figure 99.3 is an image at the level of the esophogastric anastamosis from a computed tomography (CT) scan
through the chest with oral contrast. An extraluminal collection of contrast is identied (black arrow), just
lateral to anastomosis (white arrow).
▶ Esophagram (Fig. 99.4) conrms the diagnosis with extraluminal contrast pooling in the posterior
mediastinum (black arrow).
▶ Placement of a drainage catheter within the collection (Fig. 99.5, white arrow) is seen lateral to the esophagus,
which is identied by the presence of a nasogastric tube (black arrow).
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