Chylous Ascites and Lymphoceles: Evaluation and Interventions

Abstract

Kinmonth introduced lymphangiography in 1955 and it became an important tool in the diagnosis and treatment of malignant disease. The technique, based on bipedal approach, was difficult and time-consuming which limited its use in clinical practice. Cope is the father of percutaneous lymphatic interventions and he was the first person to access and intervene on the lymphatic system. After his initial work published on 1999, there has been an expansion of the lymphatic embolization techniques, particularly since the development of intranodal lymphangiography and advance lymphatic imaging. This article is focused on the evaluation and management of postoperative chylous ascites and lymphoceles. Their incidence is growing due to longer survival of cancer patients and more radical surgical approaches, leading to an increased morbidity and mortality in this patient population. Minimally invasive percutaneous lymphatic embolization is becoming a first-line therapy in patients with postoperative lymphatic leakage.

Keywords: chylous ascites; embolization; interventional radiology; lymphangiography; lymphocele.

Fig. 1

A 67-year-old patient with history of renal cell carcinoma status post left nephrectomy and lymphadenectomy. The patient developed chylous ascites and she underwent four high-volume weekly paracenteses (> 5 L). ( a ) Intranodal lymphangiography demonstrates a 25-gauge needle (arrowhead) inside the groin lymph node (arrow) and the upstream lymphatics to the pelvis. ( b ) Abdominal radiograph reveals filling of the pelvic and retroperitoneal system with ethiodol extravasation at the level of L4–L5 paraspinal region (arrow) and the lymphatics vessels/node supplying the leak (arrowhead). ( c ) Magnified view of the area of leakage (long arrow) with the lymphatic vessels (arrowheads) and the lymph node (short arrow) supplying the leak. ( d, e ) 22-gauge needle was inserted under fluoroscopy into the lymph node (arrows) closest to the leak (arrowhead). Two oblique projections were performed to confirm the location of the needles tip in the lymph node. Then, glue embolization of the lymph node was performed (dilution 1:3). ( f ) CT scan obtained 1 month after the lymphatic embolization. The patient did not require any paracentesis after the procedure. Note the contrast (glue/ethiodol) retained in the culprit lymph node (arrow).

Fig. 2

A 35-year-old man with history of germ cell tumor status post orchiectomy and retroperitoneal lymphadenectomy. The patient developed postoperative abdominal pain. ( a ) CT scan demonstrated a large retroperitoneal lymphocele (arrows) which was drained under CT guidance in the prone position. ( b ) A drain was placed and the output was 1.1 L/day. ( c ) Intranodal lymphangiography revealed two areas of leakage (arrows) and the feeding lymphatic vessels and lymph nodes (arrowheads). ( d–g ) The closest lymph nodes (arrows) to both areas of leakage were accessed with a 22-gauge needle under fluoroscopy and oblique views were obtained to confirm adequate position of the needle tip. Diluted glue was injected (1:6) and visualized under fluoroscopy extending from the node to the level of the leak (arrowhead). ( h ) Post–lymphatic embolization CT scan was performed 1 month after the procedure with resolution of the retroperitoneal lymphocele. The drainage catheter was pulled out 8 days after the lymphatic embolization.

Fig. 3

A 54-year-old man with history of prostate carcinoma status post prostatectomy and pelvic lymphadenectomy, complicated by right pelvic sidewall symptomatic lymphocele (arrows) ( a ). ( b ) The lymphocele (arrow) was drained with a 10F pigtail catheter (arrowhead) and 200 mL of fluid were aspirated. There was a daily output of 250 mL/day. ( c, d ) Intranodal lymphangiography via 25 gauge needle (arrowhead) demonstrated ethiodol extravasation into the lymphocele (arrow). ( e ) A second 25-gauge needle was use to access the lymphatic vessel supplying the lymphatic leak under fluoroscopy (arrow). ( f ) Dextrose 5% was injected through the needle (arrow) with wash out of the ethiodol in the lymphatic vessel (arrowheads) cranial to the tip of the needle. ( g ) Diluted glue (1:4) was injected with filling of the lymphatic vessel feeding the leak (arrow). ( h ) CT scan of the abdomen and pelvis performed 2 months after the lymphatic embolization with resolution of the lymphocele. The drainage catheter was removed 3 days after the embolization.