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ORIGINAL RESEARCH |
From Department of Gynecologic Surgery, Imaging, Oncology and Radiotherapy, Institut Gustave Roussy, Villejuif, France.
Address reprint requests to: Philippe Morice, MD Institut Gustave Roussy 39 rue Camille Desmoulins 94805 Villejuif France E-mail: morice{at}igr.fr
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Abstract |
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Methods: Eighty women undergoing complete para-aortic lymphadenectomy up to the level of the left renal vein for ovarian (n = 43) or cervical carcinoma (n = 37) were randomly assigned to receive drainage or no drainage of the para-aortic area. Most of patients had pelvic drainage. Abdominopelvic ultrasonography was done 8 to 12 days after surgery. Postoperative complications, duration of hospital stay, and characteristics of asymptomatic lymphocysts were studied.
Results: Forty-two women had para-aortic drainage and 38 did not. Complications occurred in 15 patients who had drainage and in 5 patients who did not have drainage (36% versus 13%; P < .02). Three patients (8%) in the undrained group had complications potentially related to drainage (symptomatic lymphocysts or ascites) compared with 11 (26%) in the drained group (
2 = 4.6; P < .05). Median duration of the hospital stay was 9 days in the undrained group and 11 days in the drained group (P < .03). The number of asymptomatic para-aortic lymphocysts detected during the ultrasonography was 9 (24%) in the undrained and 2 (5%) in the drained group (2 < 4.6; P < .05).
Conclusions: The number of asymptomatic para-aortic lymphocysts was higher in patients who did not undergo drainage, but morbidity and the duration of hospitalization were increased in these patients. Routine drainage of the retroperitoneum after para-aortic lymphadenectomy should be abandoned
Lymphadenectomy is an integral part of the surgical staging of gynecologic cancer. Lymphocysts are the most frequent complication of this procedure. After lymphadenectomy, drainage has traditionally been recommended to reduce the risk of complications. Nevertheless, in recent years, several studies have suggested that drainage after lymphadenectomy is not useful for reducing morbidity.1–3 These studies included patients who underwent pelvic lymphadenectomy (with radical hysterectomy in most cases).
Pelvic lymphadenectomy is often extended to the para-aortic area in patients treated for invasive epithelial ovarian tumor and in some with uterine cancer.4,5 One prospective study addressed the significance of drainage in patients undergoing para-aortic lymphadenectomy.6 For the past 15 years, pelvic and para-aortic lymphadenectomies have been performed in our institution for ovarian and cervical carcinoma. Until 1998, the pelvic cavity and the retroperitoneum were drained after this procedure. In 1998, we decided to conduct a randomized study to determine whether drainage of the retroperitoneum was beneficial after para-aortic lymphadenectomy.
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Materials and Methods |
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The procedure used for pelvic and para-aortic lymphadenectomy is described elsewhere.7 Pelvic lymphadenectomy included the removal of the common iliac, external iliac, and obturator node groups. Para-aortic lymphadenectomy was performed by using a transperitoneal approach, as follows. The bowel was pushed toward the upper abdomen, and the peritoneum was incised laterally toward the cecum and continued at the back of the small-bowel mesentery up to the duodenum. The right ureter and ovarian vessels were identified. The vena cava, aorta, and inferior mesenteric artery were dissected. The upper limit of the para-aortic dissection was the left renal vein, and the presacral chain, paracaval chain, and intercavoaortic chain were removed. On the left side of the aorta, the left ureter and ovarian vessels were identified and protected. The left para-aortic chain with the inframesenteric and supramesenteric groups were removed. Hemostasis and lymphostasis were carefully performed by using coagulation and clips. The pelvic and paracolic peritoneum were not closed at the end of the lymphadenectomy. The procedure used for pelvic and para-aortic lymphadenectomy was similar in patients treated for cervical or ovarian cancer; however, in the latter case ovarian vessels were removed. The entire surgical procedure was performed in a uniform manner by one of the two senior surgeons among the authors.
Patients were randomly assigned at the end of the surgical procedure but before abdominal closure. Randomization was done by using numbered envelopes held on the surgical suite. The generator and the executor of the group assignments were not the same person. In the undrained group, no drain was placed in the aortic area. In the drained group, one low-pressure drain (Bellovac; Astratech, Mölndal, Sweden) was placed in the aortic area. In six patients treated for ovarian cancer who had a minor surgical procedure in the pelvic cavity (second-look or restaging surgery), no pelvic drainage was placed. The other patients had suction drains (Bellovac; Astratech) placed in the pelvic cavity (pouch of Douglas). Pelvic drains were used because most patients received preoperative treatment that was thought to cause increased postoperative pelvic collections.
During surgery, each patient received prophylatic antibiotics; antithrombotic prophylaxis was started on the day of surgery and continued until complete ambulation was restored, unless there was a personal history of thrombosis. The drains were removed when the volume of fluid collected was less than 50 mL/day. After removal of the drains (8–12 days after surgery), each patient underwent transabdominal abdominopelvic ultrasonography (US) (Toshiba Powervision 6000; Nasuworks, Tokyo, Japan) to search for asymptomatic lymphocysts. A lymphocyst appeared as an anechoic structure more than 15 mm in diameter with thin walls. In patients with symptomatic lymphocysts (fever or pain, or both), abdominopelvic computed tomography was performed. Patients who undewent radical hysterectomy had a intravenous urography to verify the absence of a ureteral complication.
Perioperative and postoperative data (within 90 days after the surgical procedure) were collected prospectively. The duration of the operative procedure, amount of blood loss number and type of postoperative complications, and duration of hospitalization were recorded. The percentage of patients with asymptomatic lymphocysts diagnosed by using US was recorded. The median size, number, and topography of pelvic or para-aortic lymphocysts were analyzed.
On the basis of previous studies at our institution, the rate of postoperative complications according to type of surgery performed in the present series was approximately 35%.8,9 A reduction of 60% to 65% in the rate of complications and symptomatic lymphocysts in the absence of drainage or closure of the peritoneum was reported in the literature.8,10,11 With 
= 0.05 and ß = 0.20, the minimum number of participants required to detect a two-thirds reduction in the early postoperative complication rate was 34 per group. The Wilcoxon rank test was used to compare continuous variables. The 2 test was used to compare proportions, and P < .05 was considered significant.
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Results |
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). Thirty-seven women were treated for cervical cancer and 43 for ovarian cancer. Thirty-five of the women treated for cervical cancer received preoperative irradiation according to the tumor stage and size: brachytherapy in 11 patients and external radiation therapy (45 Gy) with concomitant chemotherapy followed by brachytherapy in 24 patients. Twenty-two patients treated for ovarian cancer received neoadjuvant chemotherapy before the surgical procedure.
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). Patients treated for cervical cancer underwent class III radical hysterectomy according to the Piver classification.12 In one of them, subtotal colpectomy was associated with radical hysterectomy for a cervical tumor with persistent massive involvement of the vagina after preoperative external radiation therapy. Among women treated for ovarian cancer, 6 underwent restaging or second-look surgery. Surgical procedures included peritoneal washing for cytology, multiple peritoneal biopsies, and omentectomy if it had not been performed previously (1 patient). In 20 cases, the surgical procedure consisted of cytoreductive surgery as the primary therapy, and in 18, the cytoreductive procedure was done after initial neoadjuvant chemotherapy because of advanced-stage disease.
The histologic diagnosis, mean number of lymph nodes removed, mean number of patients with positive nodes, mean number of positive nodes, and number of patients with metastatic para-aortic nodes did not differ significantly different (Table 1).
No intraoperative complications related to para-aortic lymphadenectomy (vascular or ureteral injuries) or surgery-related deaths occurred. One patient who underwent debulking surgery for ovarian cancer had an estimated blood loss of 2400 mL. Rates and types of postoperative complications are shown in Table 2. Overall, complications occurred in 13 (35%) patients treated for cervical cancer and 7 (16%) patients treated for ovarian cancer (P = .13). Five patients (13%) in the undrained group experienced complications, and 20 complications occurred in 15 patients (36%) in the drained group, a statistically significant difference (Table 2). Some of these complications, such as wound complications or thrombosis, were unrelated to para-aortic drainage, but some were related to the absence or presence of a drain: symptomatic lymphocysts (n = 11) and ascites (n = 3) requiring a percutaneous puncture. The rates of patients with complications related to drainage according to the tumor type did not differ statistically: 8 (22%) patients treated for cervical cancer and 6 (14%) treated for ovarian cancer (P =.4).
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). Three patients had ascites, one of whom (in the drained group) developed chylous ascites on the seventh day after surgery that required repeated percutaneous and surgical drainage. Eleven patients had symptomatic lymphocysts that caused febrile morbidity in 8 and pain in 3. These lymphocysts were drained surgically in 6 patient, drained by using a percutaneous radio–guided procedure in 4, and treated medically (for pain) in 1. In 10 patients, these fluid "collections" were located in the pelvic area; in 1 patient (not drained), they were in the para-aortic area. The median duration of hospitalization differed significantly between the two groups: 9 days (range, 5–23 days) in the undrained group and 11 days (range, 8–60 days) in the drained group (Table 2).
Thirty-four asymptomatic patients were found to have lymphocysts on US (19 [50%] in the undrained group and 15 [36%] in the drained group) (Table 2). The median size of these asymptomatic lymphocysts was 35 mm (range, 15–90 mm) in the undrained group and 33 mm (range, 15–60 mm) in the drained group. They were in the pelvic cavity in 23 patients and in the para-aortic area in 11 patients (with concomitant pelvic lymphocysts in 6 patients). Pelvic lymphocysts were found in 10 (26%) patients in the undrained group and 13 (31%) in the drained group. The rates of asymptomatic para-aortic lymphocysts differed significantly (24% in undrained group versus 5% in drained group).
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Discussion |
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In view of these findings, more recent studies1–3,6 attempted to evaluate the significance of suction drainage in patients undergoing pelvic lymphadenectomy. All demonstrated that drainage is not beneficial when the peritoneum is left open after pelvic lymphadenectomy. Furthermore, in the series reported by Jensen et al,1 rates of rehospitalization and morbidity directly related to the presence of drains were increased in drained patients. Only one series included patients who underwent para-aortic lymphadenectomy.6 Although this randomized study and ours share a common rationale and had similar results, they have substantial differences. The first concerns the surgical procedure. In the series reported by Benedetti-Panici et al,6 81 patients underwent para-aortic lymphadenectomy. In 60 patients treated for endometrial or ovarian cancer, this lymphadenectomy was performed up to the level of the left renal vein (complete lymphadenectomy). However, in 25% of the patients (who were treated for cervical cancer), para-aortic lymphadenectomy was done to the level of the inferior mesenteric artery (partial lymphadenectomy). In a previous study,7 we noted that 25% of patients treated for cervical cancer with metastatic para-aortic nodes had positive nodes above the level of the inferior mesenteric artery, and we concluded that para-aortic lymphadenectomy should be performed to the level of the left renal vein16 in both cervical cancer and ovarian cancer.
Our study is the largest randomized trial to date comparing use of a drain with no drainage after complete para-aortic lymphadenectomy. This represents an important difference from other studies. Most of the lymphatic efferent vessels in the lower part of the para-aortic area converge to form the right and left lumbar trunks, which join the cisterna chyli on the right lateral surface of the aorta, located between the inferior mesenteric artery and the left renal vein.17,18 Because this part of the para-aortic space is full of lymphatic trunks, completion of para-aortic lymphadenectomy up to this level could in theory increase the risk of postoperative morbidity.
Another difference between our study and that by Benedetti-Panici et al6 concerns use of drainage in the pelvic cavity. In the latter study, the group with para-aortic drainage had two drains placed, but both were inserted in the para-aortic area, the first at the level of the paracaval space (on the right side) and the second at the level of the inferior mesenteric artery (on the left side). No drains were used in the "not-drained" group. In our study, most patients had at least a pelvic drain placed in the pouch of Douglas. Only patients with a minor pelvic procedure (restaging or second-look surgery) had no pelvic drainage. In our series, when two drains were used, one of them was placed in the para-aortic area and the second pouch of Douglas to avoid postoperative accumulation of blood or fluid due to radical surgery in the pelvic cavity.
In our study, the pelvic cavity was drained in patients who underwent a pelvic procedure because 57 patients were scheduled to receive preoperative treatments that increase fluid (blood and lymph) suffusion. On the basis of data from the literature, we treat patients with bulky stage IB/II cervical cancer with preoperative external radiation therapy (45 Gy) and concomitant chemotherapy followed by uterovaginal brachytherapy (15 Gy).19–21 Patients with unresectable stage III/IV ovarian cancer receive neoadjuvant chemotherapy (three or four courses) to reduce the tumor size and thus facilitate the surgical procedure and to limit the morbidity associated with debulking surgery.22,23 The percentage of patients (70%) who received such preoperative treatments in our study is much greater than that reported in other studies with drainage (26% in the series reported by Benedetti-Panici et al6 and 8% in that reported by Jensen et al1).
All our patients underwent routine US in search of asymptomatic lymphocysts. Unlike Lopes et al,2 we observed a higher rate of asymptomatic lymphocysts in patients who were not drained (50%) than in drained patients (36%). Furthermore, in contrast to some investigators who claim that aortic lymphocysts are rare,6,24 we observed a nonnegligible rate of para-aortic lymphocysts (13.8%). This rate was significantly higher in patients without drainage than in those with drainage (24% versus 5%). Of note, the number of lymphocysts was higher in patients who were not drained, but the number of symptomatic lymphocysts was lower than that in the drained group. The addition of a para-aortic drain may have multiplied the risks of infection and thus promoted secondary infection of lymphocysts.
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Footnotes |
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Received June 7, 2000. Received in revised form August 23, 2000. Accepted October 5, 2000.
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2. Lopes AD, Hall JR, Monaghan JM. Drainage following radical hysterectomy and pelvic lymphadenectomy: Dogma or need? Obstet Gynecol 1995;86:960–3.[Abstract]
3. Patsner B. Closed-suction drainage versus no drainage following radical abdominal hysterectomy with pelvic lymphadenectomy for stage IB cervical cancer. Gynecol Oncol 1995;57:232–4.[Medline]
4. Benedetti-Panici P, Maneschi F, Scambia G, Greggi S, Cutillo G, D’Andrea G, et al. Lymphatic spread of cervical cancer: An anatomical and pathological study based on 225 radical hysterectomies with systematic pelvic and aortic lymphadenectomy. Gynecol Oncol 1996;62:19–24.[Medline]
5. Morice P, Castaigne D, Pautier P, Rey A, Haie-Meder C, Leblanc M, et al. Interest of para-aortic lymphadenectomy in patients with stage IB and II cervical carcinoma. Gynecol Oncol 1999;73:106–10.[Medline]
6. Benedetti-Panici P, Maneschi F, Cutillo G, D’Andrea G, di Palumbo VS, Conte M, et al. A randomized study comparing retroperitoneal drainage with no drainage after lymphadenectomy in gynecologic malignancies. Gynecol Oncol 1997;65:478–82.[Medline]
7. Michel G, Morice P, Castaigne D, Leblanc M, Rey A, Duvillard P. Lymphatic spread of stage IB/II cervical carcinoma: Anatomy and surgical implications. Obstet Gynecol 1998;91:360–3.[Abstract]
8. Michel G, De Iaco P, Castaigne D, el-Hassan MJ, Lobreglio R, Lhomme C, et al. Extensive cytoreductive surgery in advanced ovarian carcinoma. Eur J Gynaecol Oncol 1997;18:9–15.[Medline]
9. Morice P, Haie-Meder C, Rey A, Pautier P, Duvillard P, Castaigne D. Prognostic factors and surgical treatment for patients with bulky stage IB and II cervical carcinoma. Int J Gynecol Cancer 2000;10:238–46.
10. Caubel P, Balladur A, Foulques H, Zamora A, Lefranc JP, Blondon J. Value of non-reperitonization for preventing lymphocele after extended lymphadeno-colpo-hysterectomy. Our experience in a comparative retrospective series of 124 cases. Ann Chir 1989;43: 525–9.[Medline]
11. Thome Saint Paul M, Bremond A, Rochet Y. Absence of peritonization after pelvic cancer surgery. Results in 157 cases. J Gynecol Obstet Biol Reprod 1991;20:957–60.[Medline]
12. Piver MS, Rutledge F, Smith JP. Five classes of extended hysterectomy for women with cervical cancer. Obstet Gynecol 1974;44:265–72.
13. Pennehouat G, Mosseri V, Durand JC, Hamelin JP, Asselain B, Pilleron JP, et al. Lymphoceles and peritonization following lymphadenectomy for cancer of the uterus. J Gynecol Obstet Biol Reprod 1988;17:373–8.[Medline]
14. Franchi M, Ghezzi F, Zanaboni F, Scarabelli C, Beretta P, Donadello N. Nonclosure of peritoneum at radical abdominal hysterectomy and pelvic node dissection: A randomized study. Obstet Gynecol 1997;90:622–7.[Abstract]
15. Suzuki M, Ohwada M, Sato I. Pelvic lymphocysts following retroperitoneal lymphadenectomy: Retroperitoneal partial "no-closure" for ovarian and endometrial cancers. J Surg Oncol 1998; 68:149–52.[Medline]
16. Morice P, Castaigne D, Duvillard P. Surgical procedure for para-aortic lymphadenectomy in stage IB and II cervical carcinoma [letter]. Am J Obstet Gynecol 1998;179:1098–9.[Medline]
17. Haagensen CD, Feind CR, Herter FP, Slanetz CA, Weinberg JA.The lymphatic in cancer. Philadelphia: Saunders, 1972.
18. Gray H, Mayo Goss C. Anatomy of the human body. Philadelphia: Lea & Febiger, 1973.
19. Keys HM, Bundy BN, Stehman FB, Muderspach LI, Chafe WE, Stuggs CL 3d, et al. Cisplatin, radiation and adjuvant hysterectomy compared with radiation and adjuvant hysterectomy for bulky stage Ib cervical carcinoma. N Engl J Med 1999;340:1154–61.
20. Rose PG, Bundy BN, Watkins EB, Thigpen JT, Deppe G, Maiman MA, et al. Concurrent cisplatin-based radiotherapy and chemotherapy for locally advanced cervical cancer. N Engl J Med 1999;340:1144–53.
21. Whitney CW, Sause W, Bundy BN, Malfetano JH, Hannigan EV, Fowler WC Jr, et al. Randomized comparison of fluorouracil plus cisplatin versus hydroxyurea as an adjunct to radiation therapy in stage IIB-IVA carcinoma of the cervix with negative para-aortic lymph nodes: A Gynecologic Oncology Group and Southwest Oncology Group study. J Clin Oncol 1999;17:1339–48.
22. Van der Burg MEL, Van Lent M, Buyse M, Kobiersa A, Colombo N, Favalli G, et al. The effect of debulking surgery after induction chemotherapy on the prognosis in advanced epithelial ovarian cancer. N Engl J Med 1995;332:629–34.
23. Vergote I, De Wever I, Tjalma W, Van Gramberen M, Decloedt J, Van Dam P. Neoadjuvant chemotherapy or primary debulking surgery in advanced ovarian carcinoma: a retrospective analysis of 285 patients. Gynecol Oncol 1998;71:431–6.[Medline]
24. Petru E, Tamussino K, Lahousen M, Winter R, Pickel H, Haas J.Pelvic and paraaortic lymphocysts after radical surgery because of cervical and ovarian cancer. Am J Obstet Gynecol 1989;161:937–41.[Medline]
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