Systematic Lymphatic Repair for Reduction of Postoperative Lymphatic Leak Following Neuroblastoma Resection

Gideon Purwono; York Tien Lee; Joyce Hy Chua; Amos Hp Loh

doi:10.1016/j.jpedsurg.2024.02.016

Systematic Lymphatic Repair for Reduction of Postoperative Lymphatic Leak Following Neuroblastoma Resection

J Pediatr Surg. 2024 Feb 24:S0022-3468(24)00098-8. doi: 10.1016/j.jpedsurg.2024.02.016. Online ahead of print.

Authors

Gideon Purwono¹, York Tien Lee², Joyce Hy Chua³, Amos Hp Loh⁴

Affiliations

¹ Duke-NUS Medical School, Singapore.
² Duke-NUS Medical School, Singapore; Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore; VIVA-KKH Paediatric Brain and Solid Tumour Programme, KKH Children's Blood and Cancer Centre, KK Women's and Children's Hospital, Singapore.
³ Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore.
⁴ Duke-NUS Medical School, Singapore; Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore; VIVA-KKH Paediatric Brain and Solid Tumour Programme, KKH Children's Blood and Cancer Centre, KK Women's and Children's Hospital, Singapore. Electronic address: amos.loh.h.p@singhealth.com.sg.

PMID: 38493026
DOI: 10.1016/j.jpedsurg.2024.02.016

Abstract

Background: Gross total resection of neuroblastoma is associated with lymphatic leaks that can delay postoperative resumption of treatment. To prevent postoperative lymphatic leak, we introduced systematic lymphatic repair (SLR), which involved oversewing the entire edge of the disrupted lymphatic plane after neuroblastoma resection. We sought to study the impact of SLR on postoperative lymphatic leak and time to return to treatment.

Methods: We reviewed 60 neuroblastoma patients who underwent gross total resection at KK Women's and Children's Hospital. Patient, disease, and operative factors were correlated with surgical drainage, treatment delay and length of stay (LOS). Among patients with sufficient records, the interaction between variables associated with drainage, delay and LOS outcomes were compared in 14 patients who had SLR versus 35 historical controls who had targeted lymphatic repair (TLR).

Results: Postoperative drain duration and volume were significantly higher in tumors with ≥2 image-derived risk factors (IDRFs, P = 0.005 and P = 0.013, respectively) or vessel encasement (P = 0.031 and P = 0.024, respectively). Longer LOS was significantly associated with ≥2 IDRFs (P = 0.006). All forms of suture repair of lymphatics and use of Tachosil™ were associated with significantly longer postoperative drain duration (P < 0.05); the former was also associated with significantly higher total drain volume (P < 0.05) - indicating appropriate use of these adjuncts in patients at risk of chyle leak. In patients who had suture repair of lymphatics, SLR was significantly associated with reduced postoperative interval to chemotherapy resumption (P = 0.014, two-way ANOVA).

Conclusion: A systematic approach to repair of lymphatic channels following neuroblastoma resection can significantly reduce time to postoperative resumption of treatment.

Type of study: Clinical Research.

Level of evidence: III.

Keywords: Chyle leak; Gross total resection; Image-defined risk factors; Neuroblastoma; Retroperitoneal fascia; Systematic lymphatic repair.