Intranodal Lymphangiography and Lymphatic Embolization for Management of Iatrogenic Chylous Ascites in Children

Abstract

Background: To demonstrate the value of intranodal lymphangiography (INL) and lymphatic embolization (LE) in management of iatrogenic chylous ascites in children who fail conservative management. Methods and Results: Retrospective review of medical records revealed six patients (four males and two females; age range 11-39 months) who underwent eight INLs and three LEs between 2017 and 2019. In one patient, the leak was visualized and embolized. In three patients, the leak was not visualized and no embolization was done, but drain output decreased and INL was not repeated. In two patients, the leak was not visualized and no embolization was done, but drain output did not decrease and INL was repeated. Repeat INL identified a leak in one patient and targeted LE was done. Repeat INL did not identify a leak in the other patient, but empirical LE was performed at the sites suspicious for leakage after multidisciplinary discussion. INL was able to identify the site of lymphatic leak in two patients (33%). In the three patients who underwent LE (two targeted at the site of identified leak and one empirical at sites suspicious for leak), one (33%) was clinically successful and the other two required surgery to address the lymphatic leak. In three patients, chylous ascites resolved after INL alone with no additional interventions. Three patients developed complications after the procedure, but only one appears to be related to the procedure itself. Follow-up for 13.8 months (13-26 months) revealed no long-term complications or mortality. Conclusion: INL with or without LE is a safe treatment for iatrogenic pediatric chylous ascites. Early utilization before more invasive surgical intervention should be considered in light of the response to INL.

Keywords: chylous ascites; embolization; lymphangiography; lymphatics.

FIG. 1.

(a) An ultrasound image of a longitudinal section view of an inguinal lymph node (thick arrow), which is used for lymphangiography. (b) A 25-gauge needle (arrowheads) positioned within the inguinal lymph node (thick arrow) under ultrasound guidance to initiate lymphangiography. (c) A fluoroscopic image with the needle positioned within the inguinal lymph node and Lipiodol injected and flowing within the small lymphatic vessels (thin arrow).

FIG. 2.

This figure shows a fluoroscopic image of the Lipiodol-filled abdominal lymph nodes during lymphangiography, with filling in of a site of leakage seen (circle) in figure (a) followed by (b) and (c). In this group of patients, the large number of radio-opaque surgical clips make it difficult to identify a site of leakage, which is why prelymphangiography scout films are important for comparison.

FIG. 3.

This figure shows a fluoroscopic image of a 25-gauge needle (arrowheads) used to puncture the lymph node (thick arrow) immediately upstream from the site of leakage. Once the tip of the needle is confirmed to be within the lymph node using oblique views and fluoroscopic visualization of dispersal of Lipiodol upon puncturing the lymph node, glue embolization is done. Lipiodol to n-BCA ratio is decided by the operator and varies according to the distance of the site of leakage from the site of needle access for embolization. n-BCA, n-butyl cyanoacrylate.