Surgical Treatments for Perigraft Seroma Complicating Hemodialysis Grafts

Song, Dan; Moon, Chul

Abstract

PURPOSE: Perigraft seroma is an unusual complication of hemodialysis grafting that has a high rate of recurrence and graft loss. This clinicopathologic disease is manifested by a persistent, often enlarging, sterile fluid collection that is confined within a nonsecretory fibrous pseudomembrane or within a well circumscribed gray sponge-like soft tissue mass (gelatinoma) around a prosthetic graft. Effective therapy for most patients with this complication currently require multiple operations and graft replacement. The purpose of this study was to review the clinical feature and surgical treatment of the perigraft seromas that complicate hemodialysis grafts.
METHODS
We reviewed the records of 30 patients with perigraft seroma that complicated the hemodialysis grafts that they underwent from January 2000 and Decembar 2004.
RESULTS
The mean age of the patients was 55.6 years and, 27 patients had a history of hypertension. The PTFE graft was placed in the brachiobrachial position in (74% of the patients). Perigraft seroma was clinically detected within the first postoperative month in 50% of the case. The arterial anastomosis of the graft was the sites that was affected in all the casese. For treatment of perigraft seroma, 8 cases underwent aspiration and this was successful in 2 cases; one case underwent incision and drainage, but this case showed recurrence, 14 cases underwent the pseudocyst excision with graft replacement: this was success in 8 cases. For the recurrence rate, treatment by aspiration had a 75% success rate and the excision of the pseudocyst with graft replacement had a 57% success rate. 9 cases underwent a second pseudocyst excision with graft replacement with 5 cases of recurrence (55%). Histologic examination of the cyst wall or membrane demonstrated no evidence of secretory cells in the inner lining, which was comprised of fibrous tissue. The cellularity of this fibrous tissue varied from being essentially acellularto being full of , lymhocytes with the, occasional macrophages in the others cases.
CONCLUSION
The authors recommend the removal of the original graft and as much of the accompanying seroma as possible, including the pseudocapsule. A change of the prosthetic material with rerouting through a new anatomic route is advisable, if the patient's general condition and life expectancy warrant an aggressive surgical approach. When using PTFE, the assiduous avoidance of graft wetting with alcohol, povidone iodine serum and blood is essential. Atraumatic tunneling is necessary, and extensively dissection is to be avoided. Aspiration or drainage is not effective, and we advocate graft replacement. Because the recurrence rate for surgical treatment was high and the patient's recovery was delayed, the authors recommend closure of the graft, if a second recurrence occur, and then new graft should be implanted in an other site.