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• W4247678131 abstract "We would like to thank Fisher et al for their comments in response to our article regarding the use of isosulfan blue for treatment of lymphatic complications.1Bounds M.C. Endean E.D. Treatment of postoperative high-volume lymphatic complications using isosulfan blue.J Vasc Surg Venous Lymphat Disord. 2018; 6: 737-740Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Dr Fisher et al have correctly pointed out that there are other techniques used for treatment of lymphatic complications. They have highlighted two endovascular procedures for treatment of lymphatic complications: aspiration or drainage of a lymphocele with injection of a sclerosing agent into the cavity2Akhan O. Karcaaltincaba M. Ozmen M.N. Akinci D. Karcaaltincaba D. Ayhan A. Percutaneous transcatheter ethanol sclerotherapy and catheter drainage of postoperative pelvic lymphoceles.Cardiovasc Intervent Radiol. 2007; 30: 237-240Crossref PubMed Scopus (47) Google Scholar and cannulation and embolization of the lymphatic vessel.3Johnson O.W. Chick F.J. Chauhan N.R. Fairchild A.H. Fan C.M. Stecker M.S. et al.The thoracic duct: clinical importance, anatomic variation, imaging, and embolization.Eur Radiol. 2016; 26: 2482-2493Crossref PubMed Scopus (86) Google Scholar, 4Hill H. Srinivasa R.N. Gemmete J.J. Hage A. Bundy J. Chick J.F. Lymphangiography and cyanoacrylate glue embolization for the treatment of postoperative lymphatic leak after robot-assisted laparoscopic pelvic resection.J Endourol Case Rep. 2018; 4: 66-71Crossref PubMed Google Scholar Both would potentially avoid an operative intervention and general anesthesia. In responding to these comments, we would make the following observations. The authors note that the majority of lymphatic complications cited in our original paper occurred after femoral or saphenous vein harvests or femoral artery exposure. A key difference between our population of patients and that cited by the authors is the anatomic location of the index intervention. The lymphatic complications treated in our study were peripheral, primarily involving the groin, whereas those in the three studies they cite all involve what may be described as central lymphatic complications, located in the pelvis, abdomen, or thorax. Thus, the endovascular approaches cited target intracavitary lymphatic complications, whereas our report is limited to extremity lymphatic complications. The techniques and treatment options for central lymphatic complications, although they appear promising in the series and case reports cited, may not necessarily apply to peripheral wound complications and may not confer the same advantages over operative intervention. Intranodal injection of dye, as described, involves injection of dye into groin lymph nodes to visualize more centrally located lymphatic vessels that are then subsequently cannulated for embolization. The lymphatic complications that we treated were located at or distal to the groin, and it is doubtful that injection of a groin lymph node would visualize the culprit lymphatic vessel caudal to the groin. Therefore, this technique would require injection of methylene blue or isosulfan blue between the toes to identify a lymphatic, followed by a cutdown on the dorsum of the foot to cannulate the identified lymph vessel,3Johnson O.W. Chick F.J. Chauhan N.R. Fairchild A.H. Fan C.M. Stecker M.S. et al.The thoracic duct: clinical importance, anatomic variation, imaging, and embolization.Eur Radiol. 2016; 26: 2482-2493Crossref PubMed Scopus (86) Google Scholar an approach similar to the technique we described except we did not create a foot incision. As noted, our cases were performed in the operating room under general anesthesia. Because the technique we describe involves opening the skin over the lymphatic complication, we continue to believe that an operating room environment is important to maintain sterility, especially since a vessel or graft could be exposed at the base of the wound. We chose to use general anesthesia primarily for the patient's comfort but think that the procedure could be done under regional or local anesthesia. The authors also suggest that one argument for avoiding the operating room is the associated cost. As we highlighted in our report, the identification of the disrupted lymphatics usually occurs quickly, thus limiting the operative time. Based on review of the studies referenced for endovascular treatment, it would appear that intranodal injection of ethiodized oil—done to identify the abdominal or thoracic lymphatic channels—takes significant time (intranodal injection of ethiodized oil every 5 minutes or pedal injection, followed by spot images every 10 to 30 minutes).3Johnson O.W. Chick F.J. Chauhan N.R. Fairchild A.H. Fan C.M. Stecker M.S. et al.The thoracic duct: clinical importance, anatomic variation, imaging, and embolization.Eur Radiol. 2016; 26: 2482-2493Crossref PubMed Scopus (86) Google Scholar Although the procedure duration is not specifically recorded, additional time is then needed to cannulate the intra-abdominal or intrathoracic duct. There are other factors that we think favor the technique we have employed. The majority (two-thirds) of our patients had lymphocutaneous fistulas. As such, we think that the technique of aspiration and sclerotherapy in these cases would not be applicable. The reported success rate for the cited procedures was 92% for aspiration and sclerotherapy and 79% for embolization. This compares with the 94% success rate we report. Finally, the technique that we describe is not associated with radiation exposure to the patient. Treatment of lymphatic complications can be challenging, and we would agree with Fisher et al that a multidisciplinary approach is valuable. The technique we describe is simple, safe, and effective for extremity lymphatic complications, and as such, we believe it to be the preferred approach. Whereas isosulfan blue could potentially identify an intracavitary injured lymphatic, we have no experience with this application of the technique. We would concur that intracavitary lymphatic complications may be better treated with an endovascular approach. Percutaneous methods clearly provide a less invasive intervention than open thoracic, abdominal, or pelvic surgery and would be similar to percutaneous drainage of abdominal abscesses or seromas that obviates the need for potentially morbid and high-risk operative interventions in reoperative fields. We appreciate the comments and issues raised and thank the Journal for giving us the opportunity to respond to this letter. Regarding “Treatment of postoperative high-volume lymphatic complications using isosulfan blue”Journal of Vascular Surgery: Venous and Lymphatic DisordersVol. 7Issue 2PreviewIn the recent manuscript by Drs Bounds and Endean,1 “Treatment of postoperative high-volume lymphatic complications using isosulfan blue,” the authors highlight the use of isosulfan blue for identification of lymphatic injuries in postoperative patients. The authors evaluated 32 patients with 33 complications including high-output lymphocele formation (n = 11 [33%]) and lymphocutaneous fistulas (n = 22 [66%]). Most patients underwent femoral or saphenous vein harvests (n = 17 [52%]) or femoral artery exposure (n = 13 [41%]). Full-Text PDF" @default.
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