Successful Management of a High-output Lymphorrhea via Lymphaticovenous Anastomosis after Cannulation for Cardiopulmonary Bypass

Abstract

Lymphatic leaks are a rare phenomenon, but can be a troublesome and persistent problem, especially in an already debilitated patient. Historically, management of lymphorrhea has involved non- and minimally-invasive techniques of elevation, compression, aspiration, or drain placement, among others. Ligation and sclerotherapy are additional utilized techniques, directly targeting the lymphatic vessel. Microsurgical management of lymphatic leaks via lymphaticolymphatic and lymphaticovenous anastomosis has gained popularity amongst surgeons as an alternative solution to the problem. We present a patient who developed a high-output lymphocutaneous fistula after a femoral cannulation procedure for cardiopulmonary bypass for an orthotopic heart transplantation. After multiple unsuccessful attempts at traditional management options, the patient had a successful resolution of the high-output lymphorrhea via a lymphaticovenous anastomosis utilizing end-to-end coaptation with an interpositional vein graft. This case uniquely describes a lymphaticovenous anastomosis and bypass of a lymph node in the setting of significant lymphorrhea (>1.0 L per day) and associated lymphocutaneous fistula, that was effectively managed in the acute postoperative setting. Management of lymphorrhea by microsurgical techniques and lymphatic vessel manipulation in the postoperative period provides surgeons with an enhanced option for direct operative management of lymphatic vessels and their associated sequelae.

Fig. 1.

One of the four lymphatic channels, with a clip preventing lymphatic leakage (blue arrow) converging into scarred lymph node (black arrow). An interposition vein graft already sewn into the recipient vein.

Fig. 2.

Completed lymphaticovenous anastomosis with bypass of scarred lymph node and interposition vein graft (black arrow). Lymphatics being intussuscepted (blue arrow).

Fig. 3.

Prealbumin trend during hospital course with dates labeled on the x-axis. The red line represents the first operation (lymphaticovenous anastomosis and lymph node bypass), and the green line represents the second operation (Dacron graft removal and rectus femoris muscle flap).