Percutaneous Treatment of Chylous Ascites

Chylous Ascites Associated with Advanced Pancreatic Cancer That Improved with Appropriate Treatment: A Case Report

Chylous ascites is a rare form of ascites with high triglyceride content arising from the thoracoabdominal lymph nodes in the peritoneal cavity due to various benign or malignant etiologies, including pancreatic cancer. During cancer chemotherapy, the accumulation of ascites can lead to the deterioration of the patient's general condition, making chemotherapy administration difficult, and resulting in a poor prognosis. We encountered a rare case of chylous ascites complicated by advanced pancreatic cancer. The patient presented with a discrepancy between the shrinkage of the pancreatic cancer and the accumulation of ascites. Therefore, we were able to promptly diagnose chylous ascites by performing biochemical tests. The patient was treated with octreotide, reportedly effective in treating chylous ascites, which rapidly improved the chylous ascites and general condition of the patient, allowing the patient to continue chemotherapy for pancreatic cancer. Therefore, physicians should consider the possibility of chylous ascites when clinically unexplained ascites are observed in patients with advanced cancer. The investigation and treatment of chylous ascites should be initiated as soon as possible.

Chyloperitoneum After Penetrating Abdominal Trauma: A Report of a Rare Case

The term chyloperitoneum refers to the accumulation of triglyceride-rich fluid in the peritoneal cavity. It is an uncommon clinical condition that usually occurs due to disruption of lymphatic flow secondary to trauma or obstruction. Common causes include penetrating or blunt trauma, iatrogenic injuries, congenital anomalies, malignant neoplasms, infections such as tuberculosis and filariasis, liver cirrhosis, constrictive pericarditis, congestive heart failure, inflammatory conditions, such as sarcoidosis and pancreatitis, and radiation- and drug-related pathologies. We present a case of chyloperitoneum in a 33-year-old woman secondary to penetrating abdominal trauma secondary to a gunshot wound. The patient was successfully managed with total parenteral nutrition and octreotide administration. To our knowledge, this is the only case of chylous ascites caused by a penetrating injury that has been reported in the literature. Conservative management with the initiation of total parenteral nutrition and octreotide led to the resolution of this condition.

A chyle leak following a tumorectomy and an axillary sentinel lymph node dissection: Case report

A chyle leak following a tumorectomy is a rare complication of surgery for breast cancer. We report a case of chylous leakage after axillary sentinel lymph node dissection. A 78-year-old woman with a left breast invasive ductal carcinoma underwent a breast-conserving surgery and had two sentinel lymph nodes removed. Ten days after surgery she came back with a swelling the left breast and the axilla, the drainage fluid was "milky". She underwent a second surgery for positive margins, during which time we did a mass ligature in the axilla and placed a drain that was remove when it wasn't productive anymore.

Intranodal Lymphangiography and Embolization for the Treatment of Early Postoperative Lymphatic Leaks after Pelvic Surgery

PURPOSE

To assess outcome and predictors of outcome after lymphatic embolization (LE) for early postoperative lymphatic leak after pelvic surgery.

MATERIAL AND METHODS

Lymphangiography (LG) procedures performed between May 2015 and February 2020 for postoperative intraperitoneal lymphatic leaks after pelvic surgery were reviewed. Treatment indication was lymphatic drainage of >500 mL/d persisting for >1 week. LE was performed by injecting glue into the iliac lymph node. Fisher exact and Wilcoxon rank-sum tests were used for comparative analysis, and logistic regression was used to assess predictors of outcome.

RESULTS

LG was performed in 71 patients. A leak was demonstrated in 69 patients who underwent LE. The mean drainage was 1,329 mL/d ± 773. Catheters were removed in 49 (69.0%) patients after 1 procedure and in 69 (97.2%) patients after a mean of 1.3 procedures. The mean drainage at the time of catheter removal was 157 mL/d ± 100. Failure occurred in 12 (16.9%) cases, including 2 (2.8%) cases of unsuccessful catheter removal and 10 (14.1%) cases of catheter reinsertion owing to recurrent ascites (n = 3) and lymphoceles (n = 7). Older age and drainage of >1,500 mL/d were associated with failure (P = .004). Drainage of >1,500 mL/d was associated with a post-LE catheter dwell time of longer than 1 week (P = .024). Minor adverse events were noted in 4 (5.6%) patients who presented with transient leg swelling.

CONCLUSIONS

LE was effective for treating pelvic surgery-related lymphatic leaks. Reintervention may be required. Drainage of >1,500 mL/d was associated with clinical failure and a post-LE catheter dwell time of longer than 1 week.

Role of Interventional Radiology in Pediatric Cancer Patients

PURPOSE OF REVIEW

Pediatric interventional radiology (IR) is a growing subspecialty. Here, we review the current role of IR in children with cancer, which uses imaging such as ultrasound, fluoroscopy, and computed tomography to perform minimally invasive procedures. These include biopsy, needle localization, central venous access, thermal ablation, transarterial chemoembolization, transarterial radioembolization with yttrium-90, non-tunneled/tunneled drainage catheter placement, and lymphatic interventions.

RECENT FINDINGS

Although locoregional therapies for the treatment of cancer in adults are common, they are less common in children, perhaps due to the relative rarity of cancer in children, their typically better performance status, and paucity of comorbidities. Preliminary results from small-scale studies for ablation, transarterial chemoembolization, and transarterial radioembolization with yttrium-90 used in the front-line armamentarium of curative therapy are encouraging. Pediatric IR offers an array of minimally invasive procedures intended to diagnose and treat pediatric cancer patients. However, more research is required to determine the efficacy of locoregional therapy in children and to define the clinical scenarios where benefit is likely to be optimized.

Novel management indications for conservative treatment of chylous ascites after gastric cancer surgery

BACKGROUND

Chylous ascites (CA) presents a challenge as a relatively common postoperative complication in gastric cancer (GC). Primary conservative therapy involved total parenteral nutrition, continuous low-pressure drainage, somatostatin, and a low-fat diet. Drainage tube (DT) clamping has been presented as a potential alternative conservative treatment for GC patients with CA.

AIM

To propose novel conservative treatment strategies for CA following GC surgery.

METHODS

The data of patients with CA after GC surgery performed at the Fudan University Shanghai Cancer Center between 2006 and 2021 were evaluated retrospectively.

RESULTS

53 patients underwent surgery for GC and exhibited postoperative CA during the study period. Postoperative hospitalization and time of DT removal showed a significant positive association (R² = 0.979, P < 0.001). We further observed that delayed DT removal significantly extended the total and postoperative hospitalization, antibiotic usage duration, and hospitalization cost (postoperative hospitalization: 25.8 d vs 15.5 d, P < 0.001; total hospitalization: 33.2 d vs 24.7 d, P < 0.01; antibiotic usage duration: 10.8 d vs 6.2 d, P < 0.01; hospitalization cost: ¥9.2 × 10⁴vs ¥6.5 × 10⁴, P < 0.01). Multivariate analysis demonstrated that postoperative infection and antibiotic usage were independent factors for delayed DT removal. Furthermore, DT removal times were shorter in seven patients who underwent DT clamping (clamped DT vs normal group, 11.8 d vs 13.6 d, P = 0.047; clamped DT vs delayed group, 13.6 d vs 27.4 d, P < 0.001). In addition, our results indicated that removal of the DT may be possible after three consecutive days of drainage volumes less than 300 mL in GC patients with CA.

CONCLUSION

Infection and antibiotic usage were vital independent factors that influenced delayed DT removal in patients with CA. Appropriate standards for DT removal can significantly reduce the duration of hospitalization. Furthermore, DT clamping might be a recommended option for conservative treatment of postoperative CA.

Chyloperitoneum due to gastric carcinoma: a case report

Chyloperitoneum is a rare manifestation of gastric carcinoma, generally occurring late in the course of the disease with a poor prognosis. We report an unusual case of chyloperitoneum in a patient with gastric carcinoma. A 61-year-old male patient presented with postprandial fullness, nausea and weight loss. The upper gastrointestinal endoscopy demonstrated a stenosing lesion of the esophagogastric junction. A biopsy was made and revealed a signet-ring cell gastric adenocarcinoma. The staging CT scan showed multiple abdominal lymphadenopathies and mild ascites. The patient underwent a staging laparoscopy that revealed a large carcinoma of the gastric cardia and a milky-appearing peritoneal fluid. A peritoneal washing and abdominal drainage were performed. The fluid analysis showed a high concentration of triglycerides, compatible with a chyloperitoneum. The patient started medium chain triglycerides-based diet with good response. This case report emphasizes that chyloperitoneum should be considered when assessing patients with gastric carcinoma.

An unusual complication of tumor surgery: chylous leakage

PURPOSE

This study was designed to evaluate the effectiveness of conservative treatment for chylous leak after tumor surgery and to propose a management algorithm.

METHODS

The data of patients with postoperative chylous leak after tumor surgery in our institution between 2010 and 2019 were retrospectively reviewed. In this study, 469 laparotomies, 89 thoracotomies, and 57 cervical excisions were performed for tumor surgery in our institution.

RESULTS

Twelve patients with a median age of 4 (IQR, 3-8) years had postoperative chylous leak. All patients received total parenteral nutrition for a median of 13 days. Five patients had intravenous somatostatin for a median of 14 days (IQR, 9-16) to decrease chyle production. Eventually, chylous leak ceased in all patients with conservative treatment and surgical drains were removed after no leak was observed with enteral feeding.

CONCLUSIONS

The incidence of chylous leak in childhood tumor surgery is approximately 2%. Extended tumor resection and lymph node dissection lead to the injury of the delicate structures that drain chyle. Conservative treatment with total parenteral nutrition and somatostatin seems to be effective. In particular, somatostatin may be used in resistant cases. Conservative treatment can take up to 1 month. The algorithm consists of how to manage postoperative chylous leak in childhood.

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

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.

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.

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.

Back to the Future: Lipiodol in Lymphography-From Diagnostics to Theranostics

Lipiodol is an iodinated poppy seed oil first synthesized in 1901. Originally developed for therapeutic purposes, it has mainly become a diagnostic contrast medium since the 1920s. At the end of the 20th century, Lipiodol underwent a transition back to a therapeutic agent, as exemplified by its increasing use in lymphangiography and lymphatic interventions. Nowadays, indications for lymphangiography include chylothorax, chylous ascites, chyluria, and peripheral lymphatic fistula or lymphoceles. In these indications, Lipiodol alone has a therapeutic effect with clinical success in 51% to 100% of cases. The 2 main access sites to the lymphatic system for lymphangiography are cannulation of lymphatic vessels in the foot (transpedal) and direct puncture of (mainly inguinal) lymph nodes (transnodal). In case of failure of lymphangiography alone to occlude the leaking lymphatic vessel as well as in indications such as protein-losing enteropathy, postoperative hepatic lymphorrhea, or plastic bronchitis, lymphatic vessels can also be embolized directly by injecting a mixture of Lipiodol and surgical glues (most commonly in thoracic duct embolization). The aim of this article is to review the historical role of Lipiodol and the evolution of its clinical application in lymphangiography over time until the current state-of-the-art lymphatic imaging techniques and interventions.

High-output chyle leak after breast-conserving surgery and sentinel lymph node biopsy

Postoperative chyle leak is an exceedingly rare complication following breast and axillary surgery. We present the first described case of chyle leak following breast-conserving surgery and sentinel lymph node biopsy. Management should begin with appropriated conservative measures aimed at reduction of lymph production and flow. Intervention is warranted when conservative strategies fail and include sclerotherapy, lymphangiography, embolization, and surgery. Breast surgeons should be mindful of this potential complication when operating in the axilla and be familiar with its stepwise management.

Chylous Ascites: A Review of Pathogenesis, Diagnosis and Treatment

Chylous ascites (CA) is a rare form of ascites that results from the leakage of lipid-rich lymph into the peritoneal cavity. This usually occurs due to trauma and rupture of the lymphatics or increased peritoneal lymphatic pressure secondary to obstruction. The underlying etiologies for CA have been classified as traumatic, congenital, infectious, neoplastic, postoperative, cirrhotic or cardiogenic. Since malignancy and cirrhosis account for about two-thirds of all the cases of CA in Western countries, in this article we have attempted to reclassify CA based on portal and non-portal etiologies. The diagnosis of CA is based on the distinct characteristic of the ascitic fluid which includes a milky appearance and a triglyceride level of >200 mg/dL. The management consists of identifying and treating the underlying disease process, dietary modification, and diuretics. Some studies have also supported the use of agents such as orlistat, somatostatin, octreotide and etilefrine. Paracentesis and surgical interventions in the form of transjugular intrahepatic portosystemic shunt (commonly known as TIPS), peritoneal shunt, angiography with embolization of a leaking vessel, and laparotomy remain as treatment options for cases refractory to medical management.