Preface: Pelvic lymph node dissection is an important part of surgery for patients with gynecologic malignancies, but this surgical approach is also associated with several potential postoperative complications. Therefore, it becomes particularly important to know how to prevent and treat pelvic lymphatic cysts. This article will address this issue.
I. Causes of pelvic lymphatic cyst formation
The exact mechanism of the formation of pelvic lymphatic cysts is not fully understood. It is generally believed that lymphatic cysts are fluid gaps left in the posterior abdominal cavity after pelvic lymph node dissection in patients with gynecologic malignancies.
Clinical manifestations of pelvic lymphatic cysts
Lymphatic cysts usually occur within 4-6 weeks after surgery. The clinical symptoms of lymphatic cysts depend mainly on their size and the site where they occur. The diameter of lymphatic cysts is mostly 2-30cm, and there are no clinical symptoms when the diameter is <5cm. Larger lymphatic cysts can produce corresponding compression symptoms, which can cause intestinal obstruction, hydronephrosis, lower limb edema and venous thrombosis, etc.
Diagnosis of pelvic lymphatic cysts
1. Palpation: a mass with large tension, clear boundary and immovable can be palpated, which can be accompanied by different degrees of pressure pain. Lymphatic cyst is firstly considered when the mass is palpated in the abdomen within 6 months after surgery, and it should be distinguished from tumor recurrence more than 6 months after surgery.
2. Ultrasound: Ultrasound examination of pelvis or groin can reveal round or oval cystic thin-walled, anechoic or fluidic dark areas of different sizes.
3. CT and MRI: CT examination results suggest a cystic watery density shadow in the iliac vascular area or inguinal area, with thin cyst wall, uniform internal density, smooth edges and clear demarcation with surrounding tissues. MRI examination results suggest a round or round-like long T1 and long T2 signal shadow with clear borders and thin and uniform cyst wall.
Differential diagnosis of pelvic lymphatic cysts
1.Pelvic inflammatory mass: Most patients with chronic pelvic inflammatory mass have no obvious systemic symptoms, mainly manifesting as lower abdominal cramps and lumbosacral discomfort. There is pressure pain, rebound pain and muscle tension on palpation in the lower abdomen. Effective antibiotic treatment.
2. pelvic hematoma: hematoma mostly occurs within a short period of time after surgery. Ultrasound examination suggests pelvic encapsulated fluid, and ultrasound-guided pelvic hematoma puncture can be performed to extract bloody or coffee-colored fluid.
3. Tumor recurrence and metastasis: it can be distinguished from lymphatic cyst according to the patient’s medical history, clinical symptoms, tumor marker detection and imaging examination results.
V. Treatment of pelvic lymphatic cysts
1.Expectation therapy: for smaller lymphatic cysts, most of them can be absorbed by themselves and do not need special treatment.
2, drug therapy: the use of traditional Chinese medicine external application, rhubarb mannitol (1:4) mixed powder, gauze bag in the lymph cyst area, with obvious effect. Chinese medicines such as Gui Zhi Fu Ling Capsules or Dispersing Nodules and Analgesic Capsules also have a certain effect in promoting the dissipation of lymphatic cysts.
3.Surgical treatment.
(1), puncture and aspiration: puncture and aspiration under ultrasound guidance is simple and easy, and it is more widely used in the clinic. However, its recurrence rate is also higher, and repeated puncture is a high-risk factor for infection.
(2), sclerotherapy: in order to reduce recurrence, sclerosing agents can be injected to produce a sterile inflammatory response in the cyst wall, which in turn causes fibrosis and atrophy of the cyst wall. Sclerosing agents include ethanol, tetracycline, doxorubicin, bleomycin, and fibrin glue. However, one must be alert to the fact that injection of sclerosing agents can cause serious complications such as atrophy and necrosis of the surrounding tissues.
(3), lymphatic cyst excision: when the above methods have no obvious effect and the compression symptoms are serious, surgical excision of the cyst can be considered, and the surgical methods include open and laparoscopic two. Open surgery can remove the cyst more completely, but it is traumatic and slow to recover.
Prevention of pelvic lymphatic cysts
1, adequate postoperative drainage: pelvic drainage has an important preventive role in preventing lymphatic cyst formation after pelvic lymphatic drainage, and placing retroperitoneal drainage can significantly reduce the incidence of lymphatic cysts.
2, keep the retroperitoneum of the pelvis open: the traditional view is that intact peritoneum can reduce abdominopelvic infection and avoid intestinal adhesions. However, closing the peritoneum can increase inflammation and foreign body reaction and lead to local ischemia of the tissues around the sutures, and more dead cavities are left in the peritoneum after suturing the pelvis, and the lymphatic fluid returning from the lower extremities is retained in the local gap, which is more likely to lead to the occurrence of lymphatic cysts.
3, intraoperative ligation of lymphatic vessels: during lymph node dissection, lymphatic vessels should be ligated as much as possible, especially the larger lymphatic trunk, which can effectively prevent the formation of lymphatic cysts.