INTRODUCTION

Although many treatment options exist for wound care, treating chronic wounds remains challenging. Maintaining a moist wound environment promotes faster healing by facilitating autolytic debridement, reducing pain and scarring, activating collagen synthesis, facilitating keratinocyte migration, and supporting the presence of crucial nutrients and growth factors in the wound microenvironment.1 However, excessive exudative discharge of ulcers negatively affects wound healing and may require more frequent dressing changes.2 Although the most common reason for excessive discharge is infection, hypoproteinemia or venous insufficiency may also lead to large amounts of discharge from leg ulcers.

The lymphatic system, which consists of lymphatic vessels and secondary lymphoid organs, parallels the cardiovascular system throughout the body. With its function of draining lymph—which consists of protein, water, and other products—back to the systemic circulation, the lymphatic system maintains the body fluid equilibrium. The lymphatic system can also regulate the immune response through cellular and humoral mechanisms. Lymphorrhea is a complication that may occur after surgical procedures with the potential to damage lymphatic vessels or lymphoid organs, such as inguinal lymph node resection. Unlike regular edema, which consists of fluid rich in water, lymphorrhea, characterized by its protein-rich fluid, can potentially induce local adverse events such as infection or delayed wound healing.3 Although lymphatic leaks can occur anywhere along the pathway of lymph that begins at any extremity, lymphatic leakage occurring after nonlymphatic system or vascular system surgeries in the lower leg is relatively rare.4

This case report describes a patient who developed a chronic leg wound caused by lymphorrhea after incision and drainage of a skin abscess. Because of lymphatic leakage, excessive discharge from the ulcer delayed granulation formation and affected the healing of the wound. However, the wound showed good granulation and epithelialization following treatment of the lymphatic leakage. The patient provided consent for his case details and images to be published.

CASE PRESENTATION

A 38-year-old man presented to the author’s outpatient clinic with a 2-week history of swelling and pain in the posterior medial part of the right leg. Physical examination revealed a 3-cm-diameter mass lesion with adjacent skin redness and swelling, and the mass exhibited obvious fluctuance. A computed tomography scan showed a low-density region of 32 × 30 × 13 mm in the subcutaneous tissue, superficial to the medial head of the gastrocnemius muscle. The diagnosis was a skin abscess in the lower extremity. The patient was treated by incision and drainage under local anesthesia. During the operation, the abscess was directly cut open to drain the pus. The wound was then debrided by removing the necrotic tissue from the cavity. Finally, the cavity was filled with silver-containing absorbent dressings and covered by 12 layers of gauze.

Wound examination and dressing changes were carried out in the outpatient department every 2 days. One week after the operation, the wound size was 40 × 40 mm, and the patient changed the dressing twice a day, which was more frequently than the provider had expected would be required. Because a skin abscess had caused the wound, infection was the main concern regarding the cause of the excessive exudation. However, the discharge of the wound was transparent and odorless, and bacterial culture of the exudate was negative. Further, the periwound skin redness became lighter in color and decreased in diameter, and the patient had no fever or pain around the wound. The provider opted to cover the wound with a foam dressing rather than gauze because, as a silver-containing absorbent dressing, the foam would absorb more discharge.

One month after the operation, the wound size remained 40 × 40 mm, and the patient still needed to change the foam dressing twice a day because of the large quantity of wound exudation. The provider carefully explored the wound and found a white tubular structure. This structure was located in the center of the wound and constantly exuded a yellowish transparent liquid (Supplemental Video, https://links.lww.com/NSW/A203). It was determined to be a lymphatic vessel. After ligation of the lymphatic vessel, the exudation stopped (Figure 1).

Figure 1.:

LIGATION OF THE LYMPHATIC VESSEL

After treatment of the lymphorrhea, the amount of exudation was significantly reduced (Figure 2A). Because of the decrease in drainage, the frequency of dressing changes was reduced from twice daily to twice per week. Fresh, healthy granulation grew quickly, and the wound size reduced to 32 × 25 mm after 2 weeks (Figure 2B). The wound had completely healed and epithelialized 4 weeks after treatment of the lymphorrhea (Figure 2C). No lymphatic adverse events such as lymphorrhea, edema, or lymphedema in the lower extremity were observed during the 2-year follow-up period.

Figure 2.:

HEALING PROGRESSA, After treating the lymphorrhea, the amount of exudation was significantly reduced. B, The wound size decreased to 32 × 25 mm after 2 weeks. C, The wound had completely healed and epithelialized after 4 weeks.

DISCUSSION

The standard treatment of skin abscesses is incision and drainage according to the current guideline.5 After incising the abscess and draining the pus, providers should remove the infective and necrotic tissue and irrigate the abscess cavity with a large amount of 0.9% sodium chloride. Postoperative debridement and regular dressing changes are also important for wound healing. Many factors can affect wound healing, including excessive necrotic tissue in the wound, smoking, obesity, and diabetes.6–8

In this case, the patient’s wound healed slowly after the incision and drainage, despite not having diabetes, obesity, or a smoking history. With debridement and daily dressing changes after the operation, little necrotic tissue was present in the wound. Thus, the continuous large amount of postoperative exudation was the main reason for the slow wound healing. Excessive exudation contains high levels of inflammatory cytokines, which prolong one or more stages in the phases of hemostasis, inflammation, proliferation, or remodeling.3

The average diameter of lymphatic vessels in the leg is 1.0 mm (range, 0.2-1.8 mm), and the vessels are divided into the anteromedial group, anterolateral group, and posterior group. The lymphatic vessels are primarily located on the anteromedial and posterior sides of the shin. The anteromedial lymphatic vessels in the proximal leg are denser and have a straighter course, and they are distributed adjacent to the great saphenous vein and its branches.9 During debridement of the proximal medial lower leg, it is necessary to maintain the integrity of the lymphatic vessels, which may be inadvertently injured.

After finding a large amount of wound exudation in this case, the provider ligated the disrupted lymphatic vessel to stop the lymphorrhea. Some reports have suggested that the treatment of postoperative lymphatic leakage is mainly based on the patient’s condition, the source of lymphatic leakage, and personal tolerance, and conservative treatment should be the first option considered.4 However, lymphocutaneous leakage after an operation may be further complicated by surgical site infection. Conservative treatment usually leads to an increased risk of wound infection, delayed wound healing, a prolonged hospital stay, and recurrence.10–12 Schwartz et al13 and Steele et al14 reported that exploration of wounds and ligation of leaking lymphatic vessels can lead to a shorter hospital stay, lower rates of adverse events, and fewer recurrences when compared with conservative treatment. Neu et al15 found that complete disappearance of the fistula or lymphocele was achieved by low-dose percutaneous radiation during therapy or shortly afterward. Gentileschi et al16 reported that lymphovenous anastomosis can stop the inflow of lymph into subcutaneous tissue and help to treat lymphorrhea. Greer et al17 reported that continuous negative-pressure wound therapy treatment of lymphatic groin fistulas was effective in selected cases. However, the current treatments for lymphatic skin leakage lack unified and recognized techniques and consistent results. Treatment is more often based on personal experience, and there is no consensus on the most effective treatment.

A limitation of this case is the lack of examination conducted to determine the presence of lymphatic duct rupture when suspicious white tubular structures were observed. Examinations such as lymphangiography and lymphoscintigraphy can confirm the presence of lymphatic leakage.4 Lymphangiography involves the real-time visualization of lymph flow by injecting substances such as indocyanine green, isosulfan blue, patent blue V dye, or ethiodized oil into lymphatic vessels on the dorsum of the foot. This method enables direct identification of broken lymphatic vessels. Lymphoscintigraphy is a nuclear medicine examination in which radiolabeled technetium 99m sulphur colloid is injected into the lymphatic system, commonly through the feet. Images are then obtained to monitor lymph flow; assess the tracer transport rate; examine the number, size, and distribution of lymph; and identify any defects in the lymphatic vessels.18 By utilizing these methods, it is possible to identify leaking lymphatic vessels that may not be visually apparent.

In this case, the author ligated the leaky lymphatic vessels. Pan et al4 found multiple lymphatic collecting vessels traveling with the great saphenous vein and its tributaries in the subcutaneous tissue of the anteromedial aspect of the lower limb. During their course, the lymphatic vessels branched, converged, diverged, crossed over, or anastomosed with neighboring vessels. When ligating leaky lymphatic vessels in the anteromedial side of the leg, the adjacent lymphatic vessels enhance the circulation of the lymph, reducing the probability of lymphedema after ligation. Performance of lymphovenous anastomosis requires a supramicrosurgical technique under microscopy in a clean wound.16 This method would not have been suitable for the contaminated open wound caused by incision and drainage of a skin abscess in the present patient.

CONCLUSIONS

Lymphorrhea, which leads to a large amount of exudation, is a surgical complication that may cause a chronic wound. Conservative treatment of lymphatic leakage would be very time-consuming. For superficial lymphatic leakage, the damaged lymphatic vessels can be explored. As shown by this case, ligation of the lymphatic vessel is easy to perform and does not generate lymphedema in the lymphatic vessels that are densely distributed throughout the region of the lower limb. Treatment of lymphorrhea promotes rapid healing of chronic leg wounds.

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