Therapeutic lymphangiography with ethiodized oil for the management of lymphoceles and chylous ascites.

PURPOSE: The purpose of this study was to analyze the safety, technical success and clinical outcome of percutaneous intranodal ethiodized oil (Lipiodol®) based lymphangiography (L-LAG) for the management of refractory pelvic lymphoceles or chylous ascites using high doses of ethiodized oil. MATERIALS AND METHODS: Thirty-four patients presenting with symptomatic, refractory postoperative pelvic lymphocele or chylous ascites referred for theranostic, inguinal, intranodal L-LAG treatment between May 2018 and November 2021 were retrospectively included. There were 21 men and 13 women, with a mean age of 62.7 ± 16.2 (standard deviation) years (age range: 9-86 years), who underwent a total of 49 L-LAG for the management of lymphoceles (n = 14), chylous ascites (n = 18) or a combination of lymphocele and chylous ascites (n = 2). Clinical and radiological pre-interventional, procedural and follow-up data up to January 2022 were collected from patients' electronic medical records and imaging files. RESULTS: Technical success was obtained in 48 out of 49 L-LAG (98%). No complications related to L-LAG were noted. After one or more L-LAG, clinical success was obtained in 30 patients (88%) with a mean of 1.4 interventions per patient and mean intranodal injected volume of 29 mL of ethiodized oil per session. The remaining four patients (12%), with one or more failed L-LAG, underwent additional surgical intervention to definitively treat the postoperative lymphatic leakage. CONCLUSION: L-LAG using high doses of ethiodized oil is a minimally invasive, safe and effective treatment of postoperative pelvic lymphocele or chylous ascites. Multiple sessions may be needed to obtain a meaningful clinical result.

[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.

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.

Glue Embolization of Lymphopseudoaneurysm for Chylous Ascites after Retroperitoneal Surgery.

OBJECTIVE: To assess the safety and efficacy of lymphopseudoaneurysm (LPA) glue (n-butyl cyanoacrylate [NBCA]) embolization in the management of chylous ascites after retroperitoneal surgery. MATERIALS AND METHODS: A retrospective analysis from January 2014 to October 2018 was performed in six patients (4 females and 2 males; mean age, 45.3 ± 14.2 years; range, 26-61 years) who underwent LPA embolization for chylous ascites developing after retroperitoneal surgery involving the perirenal space (four donor nephrectomies, one partial nephrectomy, and one retroperitoneal lymphadenectomy). After placing a percutaneous drainage catheter into the LPA or adjacent lymphocele, embolization was performed by filling the LPA itself with a mixture of glue and Lipiodol (Guerbet). RESULTS: Daily drainage from percutaneously placed drains exceeded 300 mL/day despite medical and surgical treatment (volume: mean, 1173 ± 1098 mL; range, 305-2800 mL). Intranodal lymphangiography was performed in four of the six patients and revealed leakage in 2 patients. Percutaneous embolization of the LPA was successful in all patients using an NBCA and Lipiodol mixture in a ratio of 1:1-1:2 (volume: mean, 4.3 ± 1.1 mL; range, 3-6 mL). Chylous ascites was resolved and the drainage catheter was removed in all patients within 4 days after the procedure (mean, 2.0 ± 1.8 days; range, 0-4 days). No procedure-related complications or recurrence of chylous ascites occurred during a mean follow-up period of 37.3 months (range, 21.1-48.4 months). CONCLUSION: Glue embolization of LPA has the potential to be a feasible and effective treatment method for the management of chylous ascites after retroperitoneal surgery.

Refractory Lymphatic Ascites After Radical Prostatectomy.

Lymphatic ascites after pelvic lymphadenectomy is a rare complication and is rarely reported after urologic surgery. We report a case of delayed and refractory lymphatic ascites following robotic-assisted laparoscopic radical prostatectomy.

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.

Conventional Lymphangiography (CL) in the Management of Postoperative Lymphatic Leakage (PLL): A Systematic Review.

BACKGROUND: Postoperative lymphatic leakage (PLL) is usually managed by conservative and/or surgical treatments but these procedures can be challenging to perform and potentially clinically ineffective. Therefore, conventional lymphangiography (CL) has emerged as an important alternative. The aim of this review is to present the available outcome data on CL in the management of PLL. METHOD: A systematic literature search (PubMed) using the MeSH term "lymphangiography" was performed and the search was restricted to literature published between January 2007 and August 2019. Identification, screening, and assessment for eligibility and inclusion were conducted in accordance with PRISMA. RESULTS: From the initially obtained 1006 articles (identification), 28 articles with a total of 201 patients were finally included (inclusion). The methodological quality of all included articles corresponds to level 4 (Oxford Centre for Evidence-based Medicine - Levels of Evidence, March 2009). PLL occurs after oncological and non-oncological surgery in the form of chylothorax, chylous ascites, and cervical, thoracic, abdominal and peripheral lymph fistula and/or lymphocele. The technical success rate of CL is 75-100 %. Access for CL is transpedal (176 patients) or intranodal (25 patients). Lipiodol is used as the contrast material in all articles, with a maximum amount of 20 ml for transpedal CL and 30 ml for intranodal CL. The X-ray imaging modalities used for CL are fluoroscopy, radiography and/or CT. Two articles report CL-associated major complications and CL-associated morbidity and mortality. The PLL cure rate is 51-70 % for transpedal CL (time to PLL cure: 2-29 days) and 33-100 % for intranodal CL (time to PLL cure: 2-< 30 days). Bailout procedures in the case of clinically ineffective CL include a range of treatments. CONCLUSION: CL is feasible, safe, and effective in the management of PLL. Lipiodol as the contrast material is essential in CL because the highly viscous iodinated poppy-seed oil has not only diagnostic but therapeutic effects. Guidelines and randomized controlled trials are further steps towards defining the ultimate value of CL. KEY POINTS: · PLL is a difficult-to-treat and potentially life-threatening surgical complication.. · CL has emerged as an alternative to conservative/surgical treatment of PLL.. · CL is feasible, safe, and effective in the management of PLL. · Lipiodol-based CL can be regarded as a therapeutic procedure.. · Guidelines and randomized controlled trials are further important steps.. CITATION FORMAT: · Sommer CM, Pieper CC, Itkin M et al. Conventional Lymphangiography (CL) in the Management of Postoperative Lymphatic Leakage (PLL): A Systematic Review. Fortschr Röntgenstr 2020; 192: 1025 - 1035.

A Massive Chylous Ascites With Severe Morbidity After Laparoscopic Donor Nephrectomy and Successful Treatment With Total Parenteral Nutrition and Octreotide.

Kidney transplant is a choice option for treatment of chronic kidney failure because it is associated with cost-effective and normal quality of life. To increase the number of living kidney donors, laparoscopic and minimal invasive modalities have been introduced. Here, we present a case of a living donor with an extremely rare complication after laparoscopic donor nephrectomy that presented as massive chylous ascites. Kidney donor operation can be performed with the use of 3 modalities: traditional open, laparoscopic, and open with minimally invasive. All 3 modalities may be associated with some complications, including wound infection, hemorrhaging, and deep vein thrombosis. With regard to rare complications of chylous ascites after laparoscopic donor nephrectomy, few cases have been reported. To our knowledge, only 5 such cases have been reported thus far. Our patient, a 29-year-old male donor, received left donor nephrectomy via laparoscopy and was discharged 4 days later in good condition and without any problems. However, 3 weeks later, he presented with abdominal pain. During evaluation, massive ascites in the abdomen was observed and he was hospitalized. Abdominal paracentesis was performed and chylous ascites was diagnosed, and he was treated with conservative treatment, which included combined total parenteral nutrition, paracentesis, and octreotide. For this rare complication of massive chylous ascites afterlaparoscopic donor nephrectomy, treatment with total parenteral nutrition and octreotide can be used; however, care must be taken regarding clipping of the lymph vessel of hilum of the kidney during nephrectomy.

Intranodal lymphangiography in the treatment of chylous ascites. / Linfografía intranodal en el tratamiento de la ascitis quilosa.

Chylous ascites is the presence of lymph from the thorax or bowel in the abdominal cavity. In Western countries, the most common causes of chylous ascites in adults are tumors, cirrhosis, and postoperative leakage, whereas the most common causes in children are congenital lymphatic anomalies and trauma. By contrast, in developing countries, infectious causes are responsible for most cases of chylous ascites. We present a case of chylous ascites secondary to acute necrotizing pancreatitis refractory to conservative treatment that was definitively resolved after intranodal lymphangiography with lipiodol. This is a safe and efficacious minimally invasive treatment for lymphatic leakage.

Therapeutic intranodal lymphangiography for refractory chylous ascites complicating acute necrotic pancreatitis.

Chylous ascites is a rare complication of acute pancreatitis. However, the incidence of intraperitoneal chyle leakage related to severe pancreatitis may be much higher. This is probably the result of direct damage to the cisterna chyli or its tributaries by pancreatic enzymes. In this case, conservative treatment failed to resolve the chyle leak. For the first time, to our knowledge, ultrasound guided therapeutic intranodal lymphangiography was shown to be a successful, minimally invasive treatment option in chylous ascites complicating acute necrotic pancreatitis.

Direct lymphangiography as treatment option of lymphatic leakage: indications, outcomes and role in patient's management.

BACKGROUND: To evaluate the effectiveness of lymphography as a minimally invasive treatment option of lymphatic leakage in terms of local control and to investigate which parameters influence the success rate. METHOD: This retrospective study protocol was approved by the ethic committee. Patient history, imaging data, therapeutic options and follow-up were recorded and retrospectively analyzed. Between June 1998 and February 2013, 71 patients (m:w = 42:29, mean age, 52.4; range 42­75 years) with lymphatic leakage in form of lymphatic fistulas (n = 37), lymphocele (n = 11), chylothorax (n = 13) and chylous ascites (n = 10)underwent lymphography. Sixty-four patients (90.1%) underwent successful lymphography while lymphography failed in 7 cases. Therapeutic success was evaluated and correlated to the volume of lymphatic leakage and to the volume of the applied iodized oil. RESULT: Signs of leakage or contrast extravasation were directly detected in 64 patients. Of 64 patients, 45 patients (70.3%) were treated and cured after lymphography. Based on the lymphography findings, 19 patients (29.7%) underwent surgical intervention with a completely occlusion of lymphatic leakage. The lymphatic leak could be completely occluded in 96.8% of patients when the lymphatic drainage volume was less than 200 mL/day (n = 33). Even when lymphatic drainage was higher than 200 mL/day (n = 31),therapeutic lymphography was still successful in 58.1% of the patients. CONCLUSION: Lymphography is an effective, minimally invasive method in the detection and treatment of lymphatic leakage. The volume of lymphatic drainage per day is a significant predictor of the therapeutic success rate.

A case of refractory chylous ascites after nephrectomy successfully treated with percutaneous obliteration using adhesive glue.

Here we report a case of uncontrollable chylous ascites that developed after nephrectomy and was successfully treated with percutaneous obliteration of the lymphocele-like extravasation using ethiodized oil during lymphangiography. Under computed tomographic and fluoroscopic guidance, an N-butyl cyanoacrylate-ethiodized oil mixture was used with metallic coils to obliterate the extralymphatic leakage site. The volume of intraperitoneal drainage decreased steadily over the next 5 days, and the tube was removed. Percutaneous obliteration can be characterized as filling of the leakage site from outside the lymph vessel with no flow disruption, which contrasts with the conventional embolization approach via the cisterna chyli.

Lymphangiography in the diagnosis and localization of various chyle leaks.

PURPOSE: Chyle leaks are rare entities infrequently encountered by most physicians. However, large centers providing advanced surgical care are inevitably confronted with chyle leaks as a complication of surgery, an extension of disease, or as a primary disorder. Regardless of the etiology, proper diagnosis and localization are paramount in the management of any chyle leak. MATERIALS AND METHODS: Here we present 16 patients with 17 chyle leaks (5 chyluria, 8 chylothorax, and 4 chylous ascites) who underwent bipedal lymphangiography (LAG) and postprocedure computed tomography (CT) imaging. RESULTS: In each case, the source of the chyle leak was identified and properly localized to guide further treatment. Of the 16 patients who underwent LAG and postprocedure CT imaging, the initial LAG alone provided the diagnosis and localized the chyle leak in 4 patients (25%); the postprocedure CT imaging provided the diagnosis and localized the chyle leak in 6 patients (37.5%); and the two modalities were equal in the diagnosing and localizing the chyle leak in the remaining 6 patients (37.5%) CONCLUSION: These cases highlight the unparalleled abilities of LAG and the added benefit of post-LAG CT imaging in the diagnosis and fine anatomic localization of chyle leaks. In addition, these cases demonstrate the retained utility of LAG in these investigations despite the development of alternative tests involving CT, magnetic resonance imaging, and nuclear medicine imaging.

Effectiveness of therapeutic lymphography on lymphatic leakage.

BACKGROUND: The number of conventional lymphographies has declined markedly since the introduction of cross-sectional imaging techniques. Nevertheless, lymphography has a high potential as a reliable method to visualize and directly occlude lymphatic leaks. When used as a distinct radiological procedure with the intention to treat, this application can be described as therapeutic lymphography. PURPOSE: To investigate if therapeutic lymphography is a reliable method to treat lymphatic leakage when conservative treatment fails and to investigate which parameters influence the success rate. MATERIAL AND METHODS: Between August 1995 and January 2008, 50 patients with lymphatic leakage in form of chylothorax, chylous ascites, lymphocele, and lymphatic fistulas underwent conventional therapeutic lymphography after failure of conservative therapy. Of these 50 patients, seven could not be statistically evaluated in our retrospective study: one patient died of cancer 1 day after lymphography, and six were excluded due to various technical problems. The remaining 43 patients were evaluated. Therapeutic success was evaluated and correlated to the volume of lymphatic leakage (more or less than 500 mL/day), as assessed by drainage. RESULTS: In nearly 79% of patients, the location of the leak could be detected, and surgical intervention could be planned when therapeutic lymphography failed. Due to the irrigating effect of the contrast medium (lipiodol), the lymphatic leak could be completely occluded in 70% of patients when the lymphatic drainage volume was less than 500 mL/day. Even when lymphatic drainage was higher than 500 mL/day, therapeutic lymphography was still successful in 35% of the patients. The overall success rate in patients with failed conservative treatment was 51%. Success did not depend on other factors such as age and sex, cause of lymph duct damage, or time elapsed between lymphatic injury and intervention. CONCLUSION: Therapeutic lymphography is an effective method in the treatment of lymphatic leakage when conservative therapy fails. The volume of lymphatic drainage per day is a significant predictor of the therapeutical success rate.