Intranodal Lymphangiography and Embolization for Management of Iatrogenic Chylous Ascites after Oncological Surgery.

PURPOSE: To investigate the safety and effectiveness of intranodal lymphangiography (INL) and lymphatic embolization (LE) in management of chylous ascites after oncologic surgery. MATERIALS AND METHODS: Retrospective review of records of patients who underwent INL with or without LE from January 2017 to June 2022 was performed. Adult patients with chylous ascites after oncologic surgery referred to interventional radiology after failure of conservative treatment were included. Thirty-nine patients who underwent 55 procedures were included (34 males and 5 females). Data on patient demographics, procedural technique, outcomes, and follow-up were collected. Descriptive statistics were used to illustrate technical success, clinical success, and adverse events. Univariate logistic regression analysis was performed to evaluate factors predicting clinical success. RESULTS: INL was technically successful in 54 of 55 procedures (98%; 95% confidence interval [CI], 90%-100%). A lymphatic leak was identified in 40 procedures, and LE was attempted in 36. LE was technically successful in 33 of the 36 procedures (92%; 95% CI, 78%-98%). Clinical success, defined as resolution of ascites with no need for peritoneovenous shunt placement or additional surgery, was achieved in 22 of 39 patients (56%; 95% CI, 40%-72%). Clinical success was achieved in 18 patients after 1 procedure, and patients who required repeat procedures were less likely to achieve clinical success (odds ratio, 0.16; 95% CI, 0.04-0.66; P = .012). Four grade 1 procedural adverse events were recorded. CONCLUSIONS: INL with or without LE is a safe minimally invasive tool that can help patients with chylous ascites after oncologic surgery who failed conservative treatment avoid more invasive interventions.

Single-Center Experience With Dynamic Contrast-Enhanced Magnetic Resonance Lymphangiography for Diagnosing Lymphatic Disorders and Guiding Percutaneous Embolization.

BACKGROUND: The pragmatic role of dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL) needs to be evaluated and compared across distinct lymphatic disorders. We aimed to evaluate the performance of DCMRL for identifying the underlying causes of lymphatic disorders and to define the potential benefit of DCMRL for planning lymphatic interventions. METHODS: Patients who underwent DCMRL between August 2017 and July 2022 were included in this retrospective analysis. DCMRL was performed with intranodal injection of a gadolinium-based contrast medium through inguinal lymph nodes under local anesthesia. Technical success of DCMRL and feasibility of percutaneous embolization were assessed based on the lymphatic anatomy visualized by DCMRL. Based on the underlying causes, clinical outcomes were evaluated and compared. RESULTS: Seventy consecutive patients were included. The indications were traumatic chylothorax (n = 42), traumatic chylous ascites (n = 11), and nontraumatic lymphatic leak (n = 17). The technical success rate of DCMRL was the highest in association with nontraumatic lymphatic disorders (94.1% [16/17]), followed by traumatic chylothorax (92.9% [39/42]) and traumatic chylous ascites (81.8% [9/11]). Thirty-one (47.7%) patients among 65 patients who underwent technically successful DCMRL had feasible anatomy for intervention. Clinical success was achieved in 90.3% (28/31) of patients with feasible anatomy for radiologic intervention, while 62.5% (10/16) of patients with anatomical challenges showed improvement. Most patients with traumatic chylothorax showed improvement (92.9% [39/42]), whereas only 23.5% (4/17) of patients with nontraumatic lymphatic disorders showed clinical improvement. CONCLUSION: DCMRL can help identify the underlying causes of lymphatic disorders. The performance of DCMRL and clinical outcomes vary based on the underlying cause. The feasibility of lymphatic intervention can be determined using DCMRL, which can help in predicting clinical outcomes.

A Single-Center Experience With Percutaneous Interventional Management of Refractory Chylous Ascites.

PURPOSE: Management of chylous ascites is poorly understood with no management guidelines. We retrospectively reviewed patients treated for chylous ascites at our institution to evaluate efficacy and safety of lipiodol lymphangiography and embolization. MATERIALS AND METHODS: Seven patients underwent percutaneous interventional management of chylous ascites (average age 52.5 years, 3 female, 6 post-surgical, 1 pancreatitis) from 2012. All patients underwent lipiodol inguinal lymph node injection. Adjunctive glue embolization was performed if a leak was identified. Data were collected on the cause of chylous ascites, conservative management strategies, procedural details, and success. RESULTS: All patients had chylous ascites refractory to conservative management. Preprocedure lymphoscintigraphy identified a retroperitoneal leak in 6 patients. Seven patients underwent 12 lymphangiogram procedures; 8 were performed at our institution. Lymphangiography identified a leak in 5 patients (71%). Success was achieved in 2 patients (28%) treated at our institution after glue embolization following cannulation of the leaking lymphatic channels and 1 patient (14%) after lymphangiography alone for an overall success rate of 43% (3/7). Two patients (29%) were successfully treated after one procedure. Two patients (29%) unsuccessfully treated at our institution were referred to a specialized center in the United States. No 30 day post procedural complications. CONCLUSIONS: In our experience, lymphangiography and embolization was a safe, relatively effective and minimally invasive method for treating medically refractory chylous ascites. Complex cases required referral to a specialized institution with resources unavailable at our tertiary care center.

[A case of acute chylous peritonitis treated with ultrasound-guided intranodal lymphangiography].

An 80-year-old woman presented with acute abdominal pain and distention. A diagnosis of acute chylous peritonitis was made via contrast-enhanced computed tomography and abdominal paracentesis. She underwent ultrasound-guided intranodal lymphangiography with Lipiodol® (IL with Lipiodol), and her persistent abdominal pain was significantly reduced within a day. Moreover, her ascitic fluid showed marked improvement and paracentesis was no longer needed. Based on the findings of the study, IL with Lipiodol could be a promising minimally invasive approach in the treatment of acute chylous peritonitis.

Contrast-enhanced Interstitial Transpedal MR Lymphangiography for Thoracic Chylous Effusions.

Background Abnormalities of the central lymphatic system (CLS) are increasingly treated by interventional radiology approaches. Planning of these procedures, however, is challenging because of the lack of clinical imaging tools. Purpose To evaluate the clinical usefulness of contrast agent-enhanced interstitial transpedal MR lymphangiography in the preinterventional workup of lymphatic interventions in patients with thoracic chylous effusions. Materials and Methods Patients with chylous effusions evaluated from January 2014 and December 2017 were included in this retrospective analysis of transpedal MR lymphangiography. Indications were chylothorax (n = 19; 76%), cervical lymphatic fistula (n = 2; 8%), and combined chylothorax and chylous ascites (n = 4; 16%). Patients underwent transpedal MR lymphangiography at 1.5 T with T1-weighted imaging after interstitial pedal of gadolinium-based contrast medium under local anesthesia. Contrast-enhanced MRI was evaluated for technical success, depiction of pathologic abnormalities of the CLS, and access site for lymphatic interventions (ie, clinically useful examination). Reader agreement for image quality and overall degree of visualization was assessed with weighted κ. Interrelations between overall image quality and degree of visualization of CLS structures were assessed by Spearman ρ. Efficacy of transpedal MR lymphangiography was calculated by using radiographic lymphangiography as the reference standard. Results Twenty-five patients (mean age, 54 years ± 18 [standard deviation]; 13 men) were evaluated. Eight percent (two of 25) of examinations failed (lymphoma in one patient and technical failure in one patient). Contrast agent injection was well tolerated without complications. Interrater agreement of image quality was excellent (κ = 0.96). The degree of CLS visualization correlated with overall image quality (ρ = 0.71; P < .001). Retroperitoneal lymphatics, cisterna chyli, and thoracic duct were viewed with an accuracy of 23 of 25 (92%), 24 of 25 (96%), and 23 of 25 (92%), respectively. Anatomic variations, a lymphatic pathologic abnormality, and interventional access routes were identified with an accuracy of 22 of 25 (88%), 23 of 25 (92%), and 24 of 25 (96%), respectively. Overall, 23 of 25 (92%) transpedal MR lymphangiograms provided clinically useful information. Conclusion Transpedal interstitial MR lymphangiography was well tolerated by the patient and identified specific pathologic abnormalities causing thoracic chylous leakages before lymphatic intervention. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Maki and Itkin in this issue.

Lymphangiography with or without Embolization for the Treatment of Postoperative Chylous Ascites.

BACKGROUND: Lymphatic interventions have recently been increasingly used for treating lymphatic leak of the abdomen and pelvis. This retrospective case study series and systematic review evaluated the efficacy and safety of lymphatic interventions for the treatment of postoperative lymphatic leak of the abdomen and pelvis. METHODS: A total of 15 consecutive patients with postoperative lymphatic leak of the abdomen and pelvis treated with lymphatic interventions (i.e., diagnostic intranodal or pedal lymphangiography [LAG], i.e., potentially therapeutic or diagnostic LAG with intention to treat through embolization) at our institution were reviewed. The data of 72 patients from 13 relevant articles identified through a literature search of the MEDLINE/PubMed, EMBASE, and Cochrane databases were extracted. RESULTS: The data of 87 patients (mean age, 59 [range, 24-84] years) were pooled. The technical success rate of LAG (intranodal approach, 78.2% [68/87]; pedal approach, 21.8% [19/87]) was 97.7% (85/87; 95% confidence interval [CI], 91.5-99.9%). Of the 85 patients in whom technical success of LAG was achieved, data on clinical success were available for 47 patients (55.3%). The clinical success rate of LAG was 68.1% (32/47; 95% CI, 53.8-79.7%). Of the 85 patients in whom technical success of LAG was achieved, 38 (44.7%) underwent embolization. The technical success rate of embolization was 97.4% (37/38; 95% CI, 85.3-99.9%). The clinical success rate of embolization was 70.3% (26/37; 95% CI, 54.1-82.6%). Major complications did not occur. The overall primary and secondary clinical success rates were 65.5% (57/87; 95% CI, 55.0-74.7%) and 78.2% (68/87; 95% CI, 68.3-85.6%), respectively. CONCLUSIONS: Lymphatic interventions are safe and relatively effective adjunct to conservative therapy, with the primary and secondary clinical success rate of 65.5% and 78.2%, for postoperative lymphatic leak of the abdomen and pelvis.

Endolymphatic Balloon-Occluded Retrograde Abdominal Lymphangiography (BORAL) and Embolization (BORALE) for the Diagnosis and Treatment of Chylous Ascites: Approach, Technical Success, and Clinical Outcomes.

BACKGROUND: To describe endolymphatic balloon-occluded retrograde abdominal lymphangiography (BORAL) and embolization (BORALE) for diagnosis and treatment of chylous ascites in patients with previously unidentifiable leakage site or failed lymphatic embolization. METHODS: Two (66%) men and 1 (33%) woman with mean age of 52 years (range: 14-79 years) presented with chylous ascites and underwent BORAL or BORALE between March 2016 and February 2017. Patients presented with chylous ascites (n = 3) and with renal cell carcinoma after left nephrectomy and lymph node dissection (n = 1), metastatic Merkel cell carcinoma after left nephrectomy and adrenalectomy (n = 1), and heart transplantation after failed Fontan procedure (n = 1). Pelvic lymphangiography technical successes, complications, radiation dose, contrast volume, clinical response, and follow-up were recorded. RESULTS: Pelvic lymphangiography and BORAL were technically successful in 3 (100%) patients. BORALE was attempted in 2 (66%) patients and was technically successful in both patients (100%). No minor or major complications occurred. Mean radiation dose was 1,037 mGy (range: 391-2,264 mGy). Mean contrast was 83 mL (range: 25-150 mL). Mean blood loss was 15 mL (range: 5-30 mL). Chylous ascites resolved in all 3 (100%) patients. CONCLUSIONS: BORAL and BORALE provide a rational and effective approach for the diagnosis and treatment of patients with chylous ascites and previously unidentifiable leakage site or failed lymphatic embolization.

Endolymphatic Interventions for the Treatment of Chylothorax and Chylous Ascites in Neonates: Technical and Clinical Success and Complications.

BACKGROUND: The aim of this study was to report the technical and clinical success of performing minimally invasive endolymphatic embolization in neonates presenting with a chylothorax or chylous ascites. METHODS: Three neonates, 2 males and 1 female, with a mean age of 28 days (range: 19-39 days) presented with a chylothorax or chylous ascites that was refractory to conservative management. All 3 patients (1 previously reported) underwent intranodal lymphangiography, followed by thoracic duct embolization, with 1 patient undergoing additional sclerosis of the retroperitoneal abdominal lymphatics. RESULTS: Lymphangiography, thoracic duct embolization, and sclerosis of the retroperitoneal abdominal lymphatics were technically successful. The chylothorax resolved in both the patients. Persistent chylous ascites was noted after treatment which resolved after surgical placement of a vicryl mesh and fibrin sealant. One major complication occurred with nontarget embolization of glue into the lungs requiring embolectomy. CONCLUSIONS: Thoracic duct and retroperitoneal abdominal lymphatic embolization can be performed in neonates. Resolution of chylothorax was seen in 2 patients (one previously reported) after embolization, whereas 1 patient with chylous ascites required surgical management after endolymphatic intervention.

Point-of-Care Ultrasound in Acute Neonatal Ascites.

We present a 4-week-old neonate with acute onset of bloody stools and abdominal distention. Point-of-care ultrasound performed in the emergency department allowed for rapid diagnosis of a large amount of free intra-abdominal fluid, which together with the physical findings, prompted emergent operative exploration revealing chylous ascites. Although no areas of active volvulus were identified intraoperatively, findings in the case were suggestive of small bowel volvulus and deemed as the most likely etiology for this patient's presentation. In this report, we review the relevant aspects of ultrasonography for ascites and discuss the diagnosis of chylous ascites.

Transjugular Intrahepatic Portosystemic Shunt for the Treatment of Chylothorax and Chylous Ascites in Cirrhosis: A Case Report and Systematic Review of the Literature.

Cirrhosis-related chylothorax and chylous ascites are rare conditions. The pathophysiologic mechanism of cirrhosis-related chylous fluid collections is believed to be excessive lymph flow resulting from portal hypertension. Transjugular intrahepatic portosystemic shunt (TIPS) creation is a well-established method for reducing portal hypertension. The case of a 61-year-old man with cirrhosis-related chylothorax treated successfully with a TIPS is described. A systematic review of the literature revealed nine additional cases of chylothorax or chylous ascites treated successfully with a TIPS. These cases showed that TIPS creation may be effective and safe for the treatment of chylous fluid collections in patients with cirrhosis.

Chyloperitoneum: Diagnostic and Therapeutic Options.

Chyloperitoneum is not rare and is often associated with other chylous disorders particularly in more complex clinical conditions. An accurate diagnostic study is indispensable to plan the correct therapeutic approach, and we examined the long-term outcomes of our experience in the management of primary and secondary chyloperitoneum in fifty-eight patients (50 adults and 8 children; 34 primary and 24 secondary forms). Diagnostic assessment consisted of aracentesis, whole body lymphoscintigraphy, lymphangio-MR, and lymphangio-CT (LAG-CT). The management of chyloperitoneum consisted initially of non-operative procedures (MCT diet, TPN, octreotide). Surgical treatment was performed in patients not responsive to conservative methods and involved different options using surgical and microsurgical approaches. Microsurgical techniques included chylousvenous shunts connecting chyliferous vessels and mesenteric veins. Fibrin glue or platelet gel injection at the site of the chylous leakage was also used to treat one case of refractory secondary chyloperitoneum. Patients were followed clinically and instrumentally (echography and labs tests) for 6 months to over 5 years. We found that LAG-CT was the primary diagnostic modality to provide precise topographic information concerning the site, cause, and extension of chylous pathology, all of which allowed proper planning of therapeutic procedures. Thirty-four patients did not have a relapse of the chyloperitoneum and 22 patients had a persistence of a small quanitity of ascites with no protein imbalance. We observed early relapse of chylous ascites in 2 cases that required a peritoneal-jugular shunt leading to good outcomes. An accurate diagnostic study (above all LAG-CT) and a microsurgical approach proved to represent an effective management of chyloperitoneum refractory to non-operative treatment.

Development of chylous ascites in an infant with ventricular septal defect: a case report.

This case report describes chylous ascites associated with a CHD in a 4-month-old infant. Although atraumatic chylous ascites are a rare clinical finding, the recognition and treatment of chylous ascites influence the timing of cardiac surgery.

Evaluation of lymphatic dysplasia in patients with congenital pleural effusion and ascites using indocyanine green lymphography.

OBJECTIVES: To investigate the use of indocyanine green (ICG) lymphography in the diagnosis and assessment of the severity of lymphatic dysfunction in infants and neonates with congenital lymphatic pleural effusion and ascites. STUDY DESIGN: We performed ICG lymphography on 10 neonates and infants with congenital lymphatic pleural effusion and ascites. After the subcutaneous injection of ICG, circumferential fluorescent images of lymphatic drainage channels in the extremities and trunk were identified using an infrared camera system. The lymphographic findings were classifiable into 2 patterns-those showing a linear lymphatic pattern, suggesting normal lymphatic flow, and those showing lymphatic channels with retrograde lymphatic flow (dermal backflow pattern), suggesting an abnormal lymphatic flow. We analyzed the severity of the ICG lymphography findings and the clinical outcomes. RESULTS: Based on the ICG lymphography, the severity of lymphatic dysplasia were classified into 4 categories: mild dysplasia, moderate dysplasia, severe dysplasia, and lymphatic hypoplasia. All cases diagnosed with mild (n = 3) or moderate dysplasia (n = 2) survived, and 2 of the 4 cases diagnosed with severe dysplasia died. The duration of endotracheal intubation ranged from 1 to 17 days (median, 7) in the patients with mild or moderate dysplasia and from 25 to 110 days (median, 77) in those with severe dysplasia. CONCLUSIONS: The ICG lymphographic findings were consistent with the clinical conditions. This imaging technique may be important to the future clinical management of lymphatic dysplasia in neonates and infants.

Lymphoscintigraphy patterns in newborns and children with congenital lymphatic dysplasia.

We performed lymphoscintigraphy on 31 patients (newborns and children) affected by congenital lymphatic dysplasia according to our previously published protocol. Congenital lymphatic dysplasia may present with various degrees of clinical severity, ranging from nonimmune hydrops fetalis with visceral effusions to lymphedema alone. We recommend that lymphoscintigraphy should be strongly considered in all patients with signs of lymphatic dysplasia, including those with minimal and initial signs of lymphatic impairment, in order to obtain a very early diagnosis and to start treatment. Lymphoscintigraphy is safe and useful in the diagnosis of lymphatic dysplasia in the newborn and children. Moreover, it is well tolerated by patients and well accepted by their parents.

Disseminated mycobacterium avium complex as protein-losing enteropathy in a non-HIV patient.

Disseminated mycobacterium avium complex (MAC) causing protein-losing enteropathy (PLE) due to intestinal lymphangiectasia (IL) in a non-HIV immunocompromised state is extremely rare. We present a case of 56-year-old male who was evaluated for worsening dyspnea and found to have right-sided chylous pleural effusion as well as worsening abdominal and retroperitoneal lymphadenopathy. He had a history of psoriasis for which hewas on etanercept and alefacept which were stopped two years prior to the presentation. The evaluation revealed a MAC infection in his lymph nodes--a low CD4 count but negative for HIV. He was started on MAC therapy. He subsequently developed noninfectious diarrhea, Hypoalbuminemia, recurrentpleural effusions, ascites, and Pneumocystis jiroveci pneumonia (PJP). Despite appropriate antibiotics and management--including total parental nutrition (TPN) with a medium-chain triglyceride enriched low fat diet--the patient's clinical condition deteriorated rapidly resulting in death.