Page 30 - VOL 26 N. 72 - 2015

June 6, 2015 - Auditoire C. Roux
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CHYLOPERITONEUM: MODERN DIAGNOSTIC ASPECTS AND THERAPEUTIC OPTIONS
S.DESSALVI1,L.MOLINARI1,S.SPINACI1,C.C.CAMPISI1, F.BOCCARDO1,M.FERRARI2,C.CAMPISI1
1 Department of Surgery – Unit of Lymphatic Surgery (Chief: Prof. C. Campisi); 2 Trasfusion Center.
IRCCS S. Martino – IST, National Cancer Institute – University of Genoa, Italy Email: saradessalvi@hotmail.it
Introduction: With the term Chyloperitoneum (or Chylous Ascites) we mean the presence of chylous within the peritoneal cavity .
We distinguish idiopathic (or primary) and secondary forms. Among the secondary forms, the most frequent causes in adults are represented by iatrogenic lesions of the main afferents of the Cisterna Chyli , and malignant tumors.Other possible causes of secondary Chyloperitoneum are the abdominal trauma (open or closed), liver cirrhosis , tuberculosis , pancreatitis (acute and chronic) and filariasis. Chiloperitoneum is most often associated to other clinical features such as chylothorax, chyluria, protein Losing Enteropathy, etc.
Methods: Diagnostic tests include specific pre-operative Lymphoscintigraphy of the lower limbs, and sometimes even the upper limbs (“Whole Body Lymphoscintigraphy”), Lymphangio-MRI and Lymphangiography but, above all, the Lymphangio-CT.
Standard lymphangiography (LAG) uses liposoluble ultrafluid contrast (Lipiodol Ultrafluid) injected after isolation and cannulation of the lymphatics of the dorsum of the foot with microsurgical technique. If coupled with a CT scan (Lymphangio-CT, LAG-CT), LAG allows a more accurate assessment of disease extension, as well as the site of the obstacle and source of chylous leakage.
The main indications to the use of LAG-CT are represented by pre-operative assessment of patients affected by primary, post-traumatic and post-operative chylostatic disorders. The isolation of the lymphatic collector is performed using operative microscope magnification. Once the contrast is injected entirely, the patient undergo multi slice CT examination. LAG-CT brings about precise informations about the site of chylous dysplasia and/or fistulas, since it supplies precise relations between lymphatic-lymph nodal structures and skeletal apparatus.
Results: In the literature it is reported that lymphangiography can have also sclerosing effects on lymphatics, obtaining the closure of lymphatic fistulas in patients with chylous ascites. LAG-CT represents presently the only diagnostic investigation that can supply precise topographic information about the site, cause and extension of chylous pathology and allow to plan proper therapeutic procedures.
Discussion and conclusions: There are several treatment options that can be taken for the treatment of Chyloperitoneum , although their effectiveness is very variable, in function of etiopathogenesis and extent of the disease. Recently, we treated and solved the clinical case of a refractory secondary chyloperitoneum with the use of fibrin glue injection at the site of the chylous leakage.
An accurate diagnostic study that includes , in addition to Lymphography , also a specific surgical approach Laparoscopic/Open surgery and Microsurgery, has been shown to be effective in the treatment of Chyloperitoneum refractory to medical treatment and paracentesis.
THE ROLE OF PLASTIC; RECONSTRUCTIVE AND AESTHETIC SURGERY IN THE TREATMENT OF ADVANCED LYPHEDEMA-WHILE THE EARLY BIRD CATCHES THE WORM; THE LATE RISER STILL BENEFITS
Plastic, Reconstructive and Aesthetic Surgery & Lymphatic Surgery and Microsurgery (Director Prof. C. Campisi), IRCCS S. Martino University Hospital— IST, Genoa, Italy
CAMPISI C., BOCCARDO F.
Introduction: In lymphedema, excess adipose tissue occurs with progression of the disease because of chronic lymph stasis, and impedes lymphatic flow. Recently, liposuction has been utilized as a less-invasive procedure to remove this excess tissue. Given the existing poor lymph drainage in patients with lymphatic diseases, extra caution needs to be taken to avoid damaging the lymphatic vessels during liposuction. We have developed a new technique Fibro-Lipo-Lympho-Aspiration (FLLA) with Lymph Vessel Sparing Procedure to improve the chronic swelling of patients with advanced lymphedema. FLLA makes the lymphatic pathways are visible in the treated limb thanks to the application of PDE imaging and/or BPV dye. This visibility allows the surgeon to avoid these lymphatic channels whilst removing the maximum amount of excess tissue.
Method: Ninety patients with primary or secondary lymphedema that had already been treated by derivative/reconstructive lymphatic microsurgery under the CLyFT treatment protocol in Genoa, Italy were included in this retrospective study. All patients had achieved significant volume loss after microsurgery but all had residual fibrotic/adipose tissue that was resistant to conservative treatments. Using microlymphography techniques to highlight the lymphatic pathways, the excess adipose tissue was carefully aspirated with the FLLA procedure.
Results: The length of the 90 procedures was relatively constant; with an average of 70 minutes for the upper limb (45’ min-90’ max, SD of 14.43) and 105 minutes for the lower limb (75’ min-120’ max, SD of 10.07). Regarding the quantity of the aspirated material, for the upper limb the average was 0.72 L (range of 0.2 L-1.4 L, SD of 0.38L) and the lower limb was 2.36 L (range of 0.9 L-4 L, SD of 0.98L). No episodes of post-operative infection occurred within the six months of follow up for patients treated for upper limb or lower limb chronic lymphedema. This was a significant reduction in frequency from the pre-operative status in both the upper and lower limbs (W=0, P=0.001, n=19; and W=0, P=0.001, n=13, respectively).
Conclusion: The FLLA procedure is efficient. It is possible to complete an entire leg within 90 minutes. Recovery time is short and cosmetic results are immediate. More importantly, the removal of excess tissue is completed without further damage to lymphatic vessels. When used after microsurgery, FLLA offers the possibility of removing almost all obstacles to lymphatic flow.
THE EUROPEAN JOURNAL OF LYMPHOLOGY - Vol. XXVI - Nr. 72 - 2015
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