Interventional therapy of refractory lymphatic ascites post pelvic lymphadenectomy: a case report and literature review

Lymphatic ascites is an infrequent but severe complication that can occur a ter lymphadenectomy in a patient who had gynecologic malignancies. Without appropriate management, lymphatic ascites can induce electrolyte disorder, hypoproteinemia, immunologic dysfunction, and even life-threatening. However, the optimal management is still unknown. We report a case with successful management of refractory pelvic lymphatic ascites in a patient with cervical cancer status post laparoscopic radical hysterectomy and pelvic lymph node dissection (PLND). Ultrasound-guided intranodal lymphangiography (UGILG), an innovative procedure, was used, and a leakage point at the left iliac fossa was identified a ter unsuccessful conservative treatments. Leakage of lymphatic fluid was treated successfully by embolizing the defect area under the guide of UGILG. UGILG is a feasible and alternative procedure for the diagnosis and treatment of lymphatic ascites, especially in women with a complicated gynecological procedure.

Lymphangiography; Lymphadenectomy; Lymphatic leakage; Treatment

[1] Pan W, Yang C, Cai S, Chen Z, Cheng N, Li F, et al. Incidence and risk factors of chylous ascites after pancreatic resection. International Journal of Clinical and Experimental Medicine. 2015; 8: 4494–4500.

[2] Hara H, Mihara M, Hayashi A, Kanemaru M, Todokoro T, Yamamoto T, et al. Therapeutic strategy for lower limb lymphedema and lymphatic fistula after resection of a malignant tumor in the hip joint region: a case report. Microsurgery. 2014; 34: 224–228.

[3] Tiong HY, Goel RK, White WM, Goldfarb DA, Kaouk JH. Chylous ascites after laparoscopic donor nephrectomy. Asian Journal of Endoscopic Surgery. 2015; 8: 34–39.

[4] Kim EA, Park H, Jeong SG, Lee C, Lee JM, Park CT. Octreotide therapy for the management of refractory chylous ascites after a staging operation for endometrial adenocarcinoma. The Journal of Obstetrics and Gynaecology Research. 2015; 40: 622–626.

[5] Lee YS. Single-port laparoscopic transperitoneal infrarenal paraaortic lymphadenectomy as part of staging operation for early ovarian cancer and high grade endometrial cancer. Journal of Gynecologic Oncology. 2016; 27: e32.

[6] Frey MK, Ward NM, Caputo TA, Taylor J, Worley MJ, Slomovitz BM. Lymphatic ascites following pelvic and paraaortic lymphadenectomy procedures for gynecologic malignancies. Gynecologic Oncology. 2012; 125: 48–53.

[7] Lorenz K, Abuazab M, Sekulla C, Nguyen-Thanh P, Brauckhoff M, Dralle H. Management of lymph fistulas in thyroid surgery. Langenbeck’s Archives of Surgery. 2011; 395: 911–917.

[8] Weniger M, D’Haese JG, Angele MK, Kleespies A, Werner J, Hartwig W. Treatment options for chylous ascites after major abdominal surgery: a systematic review. American Journal of Surgery. 2016; 211: 206–213.

[9] Creavin B, Ryan E, Martin ST, Hanly A, O’Connell PR, Sheahan K, et al. Organ preservation with local excision or active surveillance following chemoradiotherapy for rectal cancer. British Journal of Cancer. 2017; 116: 169–174.

[10] Morikawa K, Takenaga S, Hasumi J, Kano A, Tatsuno S, Michimoto K, et al. Retrograde transvenous lymphatic embolization for postoperative chylous ascites: a report of three cases and literature review. Journal of Radiology Case Reports. 2020; 15: 1623–1628.

[11] Tai E, Min A, Rajan DK. A single-center experience with percutaneous interventional management of refractory chylous ascites. Canadian Association of Radiologists Journal. 2020; 846537120929429.

[12] Kim PH, Tsauo J, Shin JH. Lymphangiography with or without embolization for the treatment of post-operative chylous ascites. Annals of Vascular Surgery. 2020; 68: 351–360.

[13] Kawasaki R, Sugimoto K, Fujii M, Miyamoto N, Okada T, Yamaguchi M, et al. Therapeutic effectiveness of diagnostic lymphangiography for refractory postoperative chylothorax and chylous ascites: correlation with radiologic findings and preceding medical treatment. American Journal of Roentgenology. 2013; 201: 659– 666.

[14] Shimajiri H, Egi H, Yamamoto M, Kochi M, Mukai S, Ohdan H. Laparoscopic management of refractory chylous ascites using fluorescence navigation with indocyanine green: a case report. International Journal of Surgery Case Reports. 2019; 49: 149–152.

[15] Kong TW, Chang SJ, Kim J, Paek J, Kim SH, Won JH, et al. Risk factor analysis for massive lymphatic ascites after laparoscopic retroperitonal lymphadenectomy in gynecologic cancers and treatment using intranodal lymphangiography with glue embolization. Journal of Gynecologic Oncology. 2016; 27: e44.

[16] Hur S, Shin JH, Lee IJ, Min SK, Min SI, Ahn S, et al. Early experience in the management of postoperative lymphatic leakage using lipiodol lymphangiography and adjunctive glue embolization. Journal of Vascular and Interventional Radiology. 2016; 27: 1177–1186.

[17] Baek Y, Won JH, Kong TW, Paek J, Chang SJ, Ryu HS, Kim J. Lymphatic leak occurring after surgical lymph node dissection: a preliminary study assessing the feasibility and outcome of lymphatic embolization. CardioVascular and Interventional Radiology. 2016; 39: 1728–1735.

[18] Chu HH, Shin JH, Kim JW, Noh SY, Yang WJ, Park S. Lymphangiography and lymphatic embolization for the management of pelvic lymphocele after radical prostatectomy in prostatic cancer. CardioVascular and Interventional Radiology. 2019; 42: 873–879.

[19] Angle JF, Siddiqi NH, Wallace MJ, Kundu S, Stokes L, Wojak JC, et al. Quality improvement guidelines for percutaneous tran- scatheter embolization. Journal of Vascular and Interventional Ra- diology. 2010; 21: 1479–1486.