Endolymphatic exclusion for the treatment of pediatric chylous ascites secondary to neuroblastoma resection: report of two cases

Abstract

Chylous ascites is a rare, but highly morbid complication of oncologic resection, often associated with retroperitoneal lymphadenectomy. Conservative measures with total parenteral nutrition or lipid-reduced formulas constitute the initial mainstay therapy, but not without risks and failures. This report describes 2 endolymphatic treatment strategies for iatrogenic chylous ascites following neuroblastoma resection. Lymphatic leaks were identified using intranodal lymphangiography, targeted with cone-beam computed tomographic guidance, and embolized with n-butyl cyanoacrylate. There were no adverse outcomes, with complete resolution of chylous ascites and a mean follow-up of 26 months.

Keywords: CBCT, Cone Beam Computed Tomography; Chylous ascites; Cone beam computed tomography; Interventional radiology; Lymphatic; Oncology; Pediatrics; n-BCA, n-butyl Cyanoacrylate.

Fig. 1

Frontal fluoroscopic image following bilateral inguinal access and lymphangiography using ethiodized oil (A) demonstrated two foci of lymphatic extravasation in the retroperitoneum (arrows). Following prone positioning, foci of extravasation were targeted using cone beam CT guidance (B). Lymphatic fluid draining from the access needles was noted (C). Each site was embolized using cyanoacrylate (D) (arrowheads).

Fig. 2

Frontal fluoroscopic image following bilateral inguinal access and lymphangiography using ethiodized oil (A) demonstrated a single focus of lymphatic extravasation in the left retroperitoneum (arrow). Cone beam CT was performed (C), confirming the focus of extravasation (arrow) and further characterizing retroperitoneal lymphatic anatomy. A left lateral external iliac chain node was identified and targeted using cone beam CT guidance with navigational overlay (XperGuide, Philips) (C). Following contrast confirmation of inline drainage to the focus of extravasation, embolization was performed using cyanoacrylate (D) with preservation of the right-ided lymphatics.