PAIN MANAGEMENT SERVICE LINE

THE ESSENTIALS OF PAIN MANAGEMENT PROCEDURES

Brought to you by:
Procedural Education Committee of the Pain Management Service Line- Resident and
Fellow Section, Society of Interventional Radiology
For comments or suggested edits, please email SIRSurvivalGuide@gmail.com

AUTHORS:

Fareed Riyaz, MD, PGY-3,

VCU Department of Radiology

EDITORS:

Hemant Kalia, MD, MPH,

Interventional Pain Management
Specialist, Rochester Regional
Health System
Joseph DeMarco, DO, SIR-RFS
Clinical Education Survival
Guide Liaison

LYMPHOCELE DRAINAGE AND SCLEROSIS

INDICATIONS
1. Lymphoceles are commonly seen following procedures such as renal transplantation,
femoral artery reconstructive surgery, or retroperitoneal dissections.
2. Most are asymptomatic; clinically symptomatic lymphoceles requiring treatment include:
A. Infected or expanding collections greater than 5 cm
B. Collections causing any of the following: localized pain or discomfort; lower limb
swelling; deep vein thrombosis; ureteral obstruction; external compression of renal
allograft vascular structures; or bowel obstruction or tenesmus
3. Treated in 2 stages: 1) aspiration and drainage, and 2) sclerosis
CONTRAINDICATIONS
1. Absolute contraindication to aspiration and drainage: no safe route to the collection
2. Relative contraindication to aspiration and drainage: coagulopathy
3. Absolute contraindication to sclerosis: collection connects with adjacent organs/spaces
PREOPERATIVE PREPARATION
1. Review patient history, physical examination, prior records, and imaging studies
2. Obtain baseline CBC, electrolytes, BUN, creatinine, PT, PTT, and INR
3. Patient should be NPO approximately 4 hours prior to procedure
CONSENT
1. Discuss treatment risks, benefits, and alternatives
2. Discuss risk of:
A. Bleeding
B. Infection
C. Recurrence
PROCEDURE
1. Treated in 2 stages: 1) aspiration and drainage, and 2) sclerosis
2. Aspiration and drainage:
A. Utilize either US or CT guidance to visualize the collection.
B. Enter the collection percutaneously and aspirate an adequate amount of fluid for
laboratory analysis
i.
Local anesthesia is generally sufficient
ii.
Needles from 18 to 15 gauge can be used; Seldinger technique can be used to
upgrade the gauge if needed
C. Inject contrast to ensure there is no communication with adjacent structures or spaces
i.
If such a communication exists, contact the referring physician to discuss
further management generally involves leaving a drainage catheter in place
D. Patient may be discharged home after being monitoring vitals and percutaneous
aspiration site for 2-3 hours
i.
Patients can be told to call or return to the emergency department if they have
excessive bleeding or signs of infection at the aspiration site
3. Analyze the aspirated fluid to verify collection is a lymphocele:
A. Send fluid for CBC, cytology, LDH, proteins, triglycerides, chylomicrons, and
creatinine
B. Lymphoceles will contain lymphocytes, and may contain chylomicrons and
triglycerides
C. Other fluid collections (i.e., seromas and urinomas) will contain other :
i.
Seromas will have a low level of leukocytes, with a higher percentage of
neutrophils than found in serum; a protein seroma-to-plasma ratio of
approximately 0.5; and a LDH seroma-to-plasma ratio of approximately 0.6
ii.
Urinomas will have a very high level of creatinine
4. Sclerosis can be performed once a laboratory diagnosis of lymphocele is demonstrated
A. Sclerosing agents include: 10% povidone-iodine (Betadine); 100% ethanol
2

(absolute alcohol); 1% or 3% sodium tetradecyl sulfate; 76% sodium

amidotrizoate; and doxycycline
B. Interventionalists most often use Betadine and absolute alcohol
C. Betadine usage:
i.
Instill 50% of the drained lymphocele volume with Betadine (max of 100 mL)
ii.
Leave catheter closed for 30-120 minutes
iii.
Then leave the catheter to bag drainage
D. Absolute alcohol usage:
i.
Instill 30-50% of the drained lymphocele volume (max of 60 mL)
ii.
Leave catheter closed for 5-10 minutes
iii.
Roll the patient from side to side to expose the entire lymphocele surface
iv.
Aspirate the alcohol completely; leave the catheter to bag drainage.
E. First few sessions should be performed with the clinician present to ensure patient
familiarity with the procedure. Patients can then perform procedure at home.
POST-OPERATIVE CARE
1. Daily volume of catheter drainage can vary from 25-400 mL/day
2. Catheter removal is performed when daily drainage volume is 10 mL/day
A. No need for repeat study with contrast before catheter is pulled as long as drainage
volume has decreased
COMPLICATIONS
1. No major complications seen in reviewed series
2. Minor complications include:
A. Catheter related infections (9%)
B. Recurrence (6%)
C. Catheter dislodgment (6%)
FOLLOW UP
1. In 95% of cases, catheter drainage and sclerosis of lymphoceles are successful in
completely treating the lymphocele.
2. This is superior to either repeated aspirations or catheter drainage alone, which are
successful in only 50% of cases, and carry an increased risk of infection.

REFERENCES
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lymphadenectomy: percutaneous catheter drainage with and without povidone-iodine
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Andrades P, Prado A. Composition of postabdominoplasty seroma. Aesthetic Plast Surg.

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3.

Gipson MG, Kondo KL. Management of lymphoceles after renal transplant: case report
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24(6): 881-884.

4.

Iwan-Zietek I, Zietek Z, Sulikowski T, et al. Minimally invasive methods for the

treatment of lymphocele after kidney transplantation. Transplant Proc. 2009; 41(8):
3073-3076.

5.

Jagannathan J, Anton T, Baweja H, et al. Evaluation and management of abdominal

lymphoceles after anterior lumbar spine surgery. Spine. 2008; 33: E852-857.

6.

Lee HS, Joo DJ, Huh KH, et al. Laparoscopic fenestration versus percutaneous catheter
drainage for lymphocele treatment after kidney transplantation. Transplant Proc. 2013;
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7.

Mahrer A, Ramchandani P, Trerotola SO, et al. Sclerotherapy in the management of

postoperative lymphocele. J Vasc Interv Radiol. 2010; 21(7): 1050-1053.

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