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CardioVascular and Interventional Radiology

, Volume 41, Issue 3, pp 415–423 | Cite as

Lymphangiography and Lymphatic Embolization for the Treatment of Refractory Chylous Ascites

  • Gregory J. Nadolski
  • Nikunj R. Chauhan
  • Maxim Itkin
Clinical Investigation

Abstract

Purpose

Assess the effectiveness of conventional lymphangiography, MR lymphangiography, and lymphatic embolization for the diagnosis and treatment of refractory chylous ascites.

Materials and Methods

A retrospective review of 31 patients (M/F:16/15, average age 52) who presented for the management of refractory chylous ascites was conducted to assess the diagnostic value of conventional and MR lymphangiography and outcome of lymphatic embolization.

Results

Of the total 31 patients, 25 presented with chylous ascites secondary to iatrogenic trauma and six patients with a non-traumatic etiology. All patients underwent conventional lymphangiography and nine underwent MR lymphangiogram. The lymphatic leak was visualized in 17/31 (55%) of the patients (15 of which were traumatic) and in 7/9 MR lymphangiograms (six traumatic and one non-traumatic). Embolization with n-BCA glue and/or coils of the leak was performed in 11 of the 17 patients whose leak was identified (65%) with resolution of chylous ascites in 9/11 (82%) patients. Lymphangiogram alone was curative in 7/20 (35%) patients. Overall, 16/31 patients (52%) had clinical resolution of ascites. Ascites resolved in 13/17 (76%) patients in whom the site of leak could be identified compared to 3/14 (21%) of patients in whom the site of leak could not be identified (p = 0.0038).

Conclusions

Lymphangiography and embolization can be used to treat chylous ascites. Identification of the site of leak is associated with significantly greater rate of clinical success compared to those whose site could not be identified.

Keywords

Chylous ascites Embolization Lymphangiography 

Notes

Compliance with Ethical Standards

Conflict of interest

The authors declared that they have no conflict of interest.

References

  1. 1.
    Cárdenas A, Chopra S. Chylous ascites. Am J Gastroenterol. 2002;97:1896–900.CrossRefPubMedGoogle Scholar
  2. 2.
    Kaas R, Rustman LD, Zoetmulder FA. Chylous ascites after oncological abdominal surgery: incidence and treatment. Eur J Surg Oncol. 2001;27:187–9.CrossRefPubMedGoogle Scholar
  3. 3.
    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. Am J Surg. 2016;211:206–13.CrossRefPubMedGoogle Scholar
  4. 4.
    Assumpcao L, Cameron JL, Wolfgang CL, Edil B, Choti MA, Herman JM, et al. Incidence and management of chyle leaks following pancreatic resection: a high volume single-center institutional experience. J Gastrointest Surg. 2008;12:1915–23.CrossRefPubMedGoogle Scholar
  5. 5.
    Leibovitch I, Mor Y, Golomb J, Ramon J. Chylous ascites after radical nephrectomy and inferior vena cava thrombectomy. Successful conservative management with somatostatin analogue. Eur Urol. 2002;41:220–2.CrossRefPubMedGoogle Scholar
  6. 6.
    Matsuda T, Fujita H, Kunimoto Y, Kimura T, Ogino K. Chylous ascites as a complication of laparoscopic colorectal surgery. Asian J Endosc Surg. 2013;6:279–84.CrossRefPubMedGoogle Scholar
  7. 7.
    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. AJR Am J Roentgenol [Internet]. Am Roentgen Ray Soc. 2013;201:659–66. Available from: http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=23971461&retmode=ref&cmd=prlinks.
  8. 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. Am J Surg [Internet]. 2016;211:206–13. Available from: http://linkinghub.elsevier.com/retrieve/pii/S000296101500327X.
  9. 9.
    Leibovitch I, Mor Y, Golomb J, Ramon J. The diagnosis and management of postoperative chylous ascites. J Urol. 2002;167:449–57.CrossRefPubMedGoogle Scholar
  10. 10.
    Evans JG, Spiess PE, Kamat AM, Wood CG, Hernandez M, Pettaway CA, et al. Chylous ascites after post-chemotherapy retroperitoneal lymph node dissection: review of the M. D. Anderson experience. J Urol. 2006;176:1463–7.CrossRefPubMedGoogle Scholar
  11. 11.
    Shapiro AM, Bain VG, Sigalet DL, Kneteman NM. Rapid resolution of chylous ascites after liver transplantation using somatostatin analog and total parenteral nutrition. Transplantation. 1996;61:1410–1.CrossRefPubMedGoogle Scholar
  12. 12.
    Huang Q, Jiang Z-W, Jiang J, Li N, Li J-S. Chylous ascites: treated with total parenteral nutrition and somatostatin. World J Gastroenterol. 2004;10:2588–91.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Matsuda T, Fujita H, Kunimoto Y, Kimura T, Ogino K. Chylous ascites as a complication of laparoscopic colorectal surgery. Asian J Endosc Surg [Internet]. 2013;6:279–84. Available from: http://proxy.library.upenn.edu:2154/doi/10.1111/ases.12057/full.
  14. 14.
    Pabst TS, McIntyre KE, Schilling JD, Hunter GC, Bernhard VM. Management of chyloperitoneum after abdominal aortic surgery. Am J Surg. 1993;166:194–9.CrossRefPubMedGoogle Scholar
  15. 15.
    Matsumoto T, Yamagami T, Kato T, Hirota T, Yoshimatsu R, Masunami T, et al. The effectiveness of lymphangiography as a treatment method for various chyle leakages. Br J Radiol [Internet]. 2009;82:286–90. Available from: http://www.birpublications.org/doi/abs/10.1259/bjr/64849421.
  16. 16.
    Dori Y, Keller MS, Rome JJ, Gillespie MJ, Glatz AC, Dodds K, et al. Percutaneous lymphatic embolization of abnormal pulmonary lymphatic flow as treatment of plastic bronchitis in patients with congenital heart disease. Circulation. 2016;133:1160–70.CrossRefPubMedGoogle Scholar
  17. 17.
    Mittleider D, Dykes T, Cicuto K, Amberson S, Leusner C. Retrograde cannulation of the thoracic duct and embolization of the cisterna chyli in the treatment of chylous ascites. J Vasc Interv Radiol. 2008;19:285–90.CrossRefPubMedGoogle Scholar
  18. 18.
    Itou C, Koizumi J, Myojin K, Yamashita T, Mori N, Imai Y. A case of refractory chylous ascites after nephrectomy successfully treated with percutaneous obliteration using adhesive glue. Jpn J Radiol. 2013;31:71–4.CrossRefPubMedGoogle Scholar
  19. 19.
    Ching KC, Santos E, McCluskey K, Jeyabalan G. Sign in CT-guided injection of N-butyl cyanoacrylate glue for treatment of chylous leak after aorto-mesenteric Bypass. Cardiovasc Interv Radiol. 2014;37(4):1103–6.CrossRefGoogle Scholar
  20. 20.
    Kortes N, Radeleff B, Sommer C-M, Bellemann N, Ott K, Richter GM, et al. Therapeutic lymphangiography and CT-guided sclerotherapy for the treatment of refractory lymphatic leakage. J Vasc Interv Radiol. 2014;25:127–32.CrossRefPubMedGoogle Scholar
  21. 21.
    Pieper CC, Schild HH. Successful minimally invasive treatment of intractable, postoperative chylous ascites via percutaneous lymph vessel embolization. Cardiovasc Intervent Radiol. 2015;38:1050–4.CrossRefPubMedGoogle Scholar
  22. 22.
    Dinç H, Oğuz Ş, Sarı A. A novel technique in the treatment of retroperitoneal lymphatic leakage: direct percutaneous embolization through the leakage pouch. Diagn Interv Radiol Turk Soc Radiol. 2015;21:419–22.CrossRefGoogle Scholar
  23. 23.
    Nadolski GJ, Itkin M. Feasibility of ultrasound-guided intranodal lymphangiogram for thoracic duct embolization. J Vasc Interv Radiol. 2012;23:613–6.CrossRefPubMedGoogle Scholar
  24. 24.
    Guermazi A, Brice P, Hennequin C, Sarfati E. Lymphography: an old technique retains its usefulness. Radiographics. 2003;23:1541–58 (discussion 1559–60).CrossRefPubMedGoogle Scholar
  25. 25.
    Dori Y, Zviman MM, Itkin M. Dynamic contrast-enhanced MR lymphangiography: feasibility study in swine. Radiology. 2014;273:410–6.CrossRefPubMedGoogle Scholar
  26. 26.
    Itkin M, Kucharczuk JC, Kwak A, Trerotola SO, Kaiser LR. Nonoperative thoracic duct embolization for traumatic thoracic duct leak: experience in 109 patients. J Thorac Cardiovasc Surg. 2010;139:584–9 (discussion 589–90).CrossRefPubMedGoogle Scholar
  27. 27.
    Hur S, Shin JH, Lee IJ, Min S-K, Min S-I, Ahn S, et al. Early experience in the management of postoperative lymphatic leakage using lipiodol lymphangiography and adjunctive glue embolization. J Vasc Interv Radiol. 2016;27(1177–1186):e1.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2017

Authors and Affiliations

  1. 1.Center for Lymphatic Imaging and InterventionsPenn Medicine, Children’s Hospital of PhiladelphiaPhiladelphiaUSA
  2. 2.Radiology DepartmentCleveland ClinicClevelandUSA
  3. 3.HUP/CHOP Center for Lymphatic Imaging and InterventionsPenn Medicine, Children’s Hospital of PhiladelphiaPhiladelphiaUSA

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