RESUMEN
Pelvic lymphoceles/lymph fistulas are commonly observed after kidney allotransplantation, especially when the kidney is placed in a retroperitoneal position. While the majority are <5 cm in diameter and resolve without intervention, some may continue to enlarge, and cause local or systemic symptoms or graft dysfunction. Among 1662 recipients of both living and deceased donor kidney transplants between January 2003 and July 2014, we found 46 (2.7%) patients with symptomatic lymphoceles requiring intervention. We studied the clinical outcomes and charges for three treatment modalities including open surgical drainage (22), laparoscopic surgical drainage (11), and percutaneous fibrin glue injections into the drained lymphocele cavity (13). The patient demographics and clinical characteristics were comparable for each treatment group, although maintenance immunosuppressive drugs differed by era. We found fibrin glue injections resulted in significantly lower (p = 0.04) rates of recurrence (1; 7.7%) than either laparoscopic (6; 54%) or open surgical drainage (6; 27.3%). In addition, fibrin glue injections generated significantly (p < 0.001) lower median ($4559) charges compared to either laparoscopic ($26,330) or open surgical drainage ($23,758). Fibrin glue treatment has the advantage of being an outpatient procedure, performed with the patient under local anesthesia, and does not incur the expense of an operative procedure or hospital admission associated with laparoscopic or open surgery.
Asunto(s)
Adhesivo de Tejido de Fibrina/administración & dosificación , Fístula/economía , Fístula/terapia , Trasplante de Riñón/efectos adversos , Linfocele/economía , Linfocele/terapia , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Adulto , Cateterismo , Femenino , Fístula/etiología , Estudios de Seguimiento , Tasa de Filtración Glomerular , Rechazo de Injerto/economía , Rechazo de Injerto/etiología , Rechazo de Injerto/terapia , Supervivencia de Injerto , Costos de la Atención en Salud , Humanos , Inyecciones Intravenosas , Fallo Renal Crónico/cirugía , Pruebas de Función Renal , Laparoscopía/métodos , Linfocele/etiología , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Adhesivos Tisulares/administración & dosificaciónAsunto(s)
Fístula/terapia , Servicios de Salud Materna/provisión & distribución , Complicaciones del Embarazo/terapia , Atención Ambulatoria/organización & administración , Presupuestos , Atención a la Salud/economía , Atención a la Salud/organización & administración , Países en Desarrollo , Femenino , Fístula/economía , Hospitalización , Maternidades/economía , Maternidades/provisión & distribución , Humanos , Servicios de Salud Materna/economía , Evaluación de Necesidades , Embarazo , Complicaciones del Embarazo/economíaRESUMEN
A pharyngocutaneous fistula following a total laryngectomy is not an uncommon occurrence. The incidence of this serious complication ranges worldwide from 7.6 percent to 50 percent. It usually exacerbates post-operative morbidity and increases expense with prolonged hospitalization. This complication often requires additional operative procedures or if untreated may lead to a fatal complication such as carotid artery rupture. There are multiple predisposing factors leading to poor wound healing in this patient population. These factors include prior radiation therapy, chemotherapy, compromised nutrition, and associated surgical procedures including radical neck dissection. A treatment strategy for difficult fistulas with undermining is presented here. The cornerstones of this approach include opening the area large enough for packing and cleansing, diverting the copious pharyngeal secretions and providing an optimal wound environment through the use of an amorphous hydrogel dressing (Intrasite* Gel, Smith & Nephew United, Inc., Largo, FL). This treatment strategy led to complete and sustained healing when utilized by the authors in the following patients. It was successful even in heavily irradiated tissue with its severe changes of compromised vascularity, increased dermal fibrosis and epidermal thinning. The authors have found this technique a cost-effective alternative to secondary surgery, applicable in both the acute and home care settings.