Semin intervent Radiol 2020; 37(03): 274-284
DOI: 10.1055/s-0040-1713445
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Chylous Ascites and Lymphoceles: Evaluation and Interventions

Ernesto Santos
1   Department of Radiology, Interventional Radiology Service, Memorial Sloan Kettering Cancer Center, New York, New York
,
Amgad M. Moussa
1   Department of Radiology, Interventional Radiology Service, Memorial Sloan Kettering Cancer Center, New York, New York
› Author Affiliations
Further Information

Publication History

Publication Date:
31 July 2020 (online)

Abstract

Kinmonth introduced lymphangiography in 1955 and it became an important tool in the diagnosis and treatment of malignant disease. The technique, based on bipedal approach, was difficult and time-consuming which limited its use in clinical practice. Cope is the father of percutaneous lymphatic interventions and he was the first person to access and intervene on the lymphatic system. After his initial work published on 1999, there has been an expansion of the lymphatic embolization techniques, particularly since the development of intranodal lymphangiography and advance lymphatic imaging. This article is focused on the evaluation and management of postoperative chylous ascites and lymphoceles. Their incidence is growing due to longer survival of cancer patients and more radical surgical approaches, leading to an increased morbidity and mortality in this patient population. Minimally invasive percutaneous lymphatic embolization is becoming a first-line therapy in patients with postoperative lymphatic leakage.

 
  • References

  • 1 Bhardwaj R, Vaziri H, Gautam A, Ballesteros E, Karimeddini D, Wu GY. Chylous ascites: a review of the pathogenesis, diagnosis and treatment. J Clin Transl Hepatol 2018; 6 (01) 105-113
  • 2 Al-Busafi SA, Ghali P, Deschênes M, Wong P. Chylous ascites: evaluation and management. ISRN Hepatol 2014; 2014: 240473
  • 3 Cárdenas A, Chopra S. Chylous ascites. Am J Gastroenterol 2002; 97 (08) 1896-1900
  • 4 Aalami OO, Allen DB, Organ Jr CH. Chylous ascites: a collective review. Surgery 2000; 128 (05) 761-778
  • 5 Lopez-Gutierrez JC, Tovar JA. Chylothorax and chylous ascites: management and pitfalls. Semin Pediatr Surg 2014; 23 (05) 298-302
  • 6 Kiyonaga M, Mori H, Matsumoto S, Yamada Y, Sai M, Okada F. Thoracic duct and cisterna chyli: evaluation with multidetector row CT. Br J Radiol 2012; 85 (1016): 1052-1058
  • 7 Pamarthi V, Pabon-Ramos WM, Marnell V, Hurwitz LM. MRI of the central lymphatic system: Indications, imaging technique, and pre-procedural planning. Top Magn Reson Imaging 2017; 26 (04) 175-180
  • 8 Browse NL, Wilson NM, Russo F, al-Hassan H, Allen DR. Aetiology and treatment of chylous ascites. Br J Surg 1992; 79 (11) 1145-1150
  • 9 Steinemann DC, Dindo D, Clavien PA, Nocito A. Atraumatic chylous ascites: systematic review on symptoms and causes. J Am Coll Surg 2011; 212 (05) 899-905.e1 , 4
  • 10 Kaas R, Rustman LD, Zoetmulder FA. Chylous ascites after oncological abdominal surgery: incidence and treatment. Eur J Surg Oncol 2001; 27 (02) 187-189
  • 11 Gaglio PJ, Leevy CB, Koneru B. Peri-operative chylous ascites. J Med 1996; 27 (5-6): 369-376
  • 12 Runyon BA, Akriviadis EA, Keyser AJ. The opacity of portal hypertension-related ascites correlates with the fluid's triglyceride concentration. Am J Clin Pathol 1991; 96 (01) 142-143
  • 13 Runyon BA. ; AASLD Practice Guidelines Committee. Management of adult patients with ascites due to cirrhosis: an update. Hepatology 2009; 49 (06) 2087-2107
  • 14 Almakdisi T, Massoud S, Makdisi G. Lymphomas and chylous ascites: review of the literature. Oncologist 2005; 10 (08) 632-635
  • 15 Thaler MA, Bietenbeck A, Schulz C, Luppa PB. Establishment of triglyceride cut-off values to detect chylous ascites and pleural effusions. Clin Biochem 2017; 50 (03) 134-138
  • 16 Prasad S, Patankar T. Computed tomography demonstration of a fat-fluid level in tuberculous chylous ascites. Australas Radiol 1999; 43 (04) 542-543
  • 17 Weiss M, Schwarz F, Wallmichrath J. , et al. Chylothorax and chylous ascites. Clinical utility of planar scintigraphy and tomographic imaging with SPECT/CT. Nucl Med (Stuttg) 2015; 54 (05) 231-240
  • 18 Dori Y, Zviman MM, Itkin M. Dynamic contrast-enhanced MR lymphangiography: feasibility study in swine. Radiology 2014; 273 (02) 410-416
  • 19 Chavhan GB, Amaral JG, Temple M, Itkin M. MR lymphangiography in children: technique and potential applications. Radiographics 2017; 37 (06) 1775-1790
  • 20 Itkin M, Nadolski GJ. Modern techniques of lymphangiography and interventions: Current status and future development. Cardiovasc Intervent Radiol 2018; 41 (03) 366-376
  • 21 Pimpalwar S, Chinnadurai P, Chau A. , et al. Dynamic contrast enhanced magnetic resonance lymphangiography: categorization of imaging findings and correlation with patient management. Eur J Radiol 2018; 101: 129-135
  • 22 Nadolski GJ, Chauhan NR, Itkin M. Lymphangiography and lymphatic embolization for the treatment of refractory chylous ascites. Cardiovasc Intervent Radiol 2018; 41 (03) 415-423
  • 23 Rajebi MR, Chaudry G, Padua HM. , et al. Intranodal lymphangiography: feasibility and preliminary experience in children. J Vasc Interv Radiol 2011; 22 (09) 1300-1305
  • 24 Majdalany BS, Khayat M, Downing T. , et al. Lymphatic interventions for isolated, iatrogenic chylous ascites: a multi-institution experience. Eur J Radiol 2018; 109: 41-47
  • 25 Mittleider D, Dykes TA, Cicuto KP, Amberson SM, Leusner CR. Retrograde cannulation of the thoracic duct and embolization of the cisterna chyli in the treatment of chylous ascites. J Vasc Interv Radiol 2008; 19 (2, Pt 1): 285-290
  • 26 Guevara CJ, Rialon KL, Ramaswamy RS, Kim SK, Darcy MD. US-guided, direct puncture retrograde thoracic duct access, lymphangiography, and embolization: Feasibility and efficacy. J Vasc Interv Radiol 2016; 27 (12) 1890-1896
  • 27 Alejandre-Lafont E, Krompiec C, Rau WS, Krombach GA. Effectiveness of therapeutic lymphography on lymphatic leakage. Acta Radiol 2011; 52 (03) 305-311
  • 28 Gruber-Rouh T, Naguib NNN, Lehnert T. , et al. Direct lymphangiography as treatment option of lymphatic leakage: indications, outcomes and role in patient's management. Eur J Radiol 2014; 83 (12) 2167-2171
  • 29 Guez D, Nadolski GJ, Pukenas BA, Itkin M. Transhepatic lymphatic embolization of intractable hepatic lymphorrhea. J Vasc Interv Radiol 2014; 25 (01) 149-150
  • 30 Kojima M, Inoue M, Yamamoto S, Kanai T, Nakatsuka S, Nakagawa M. Successful treatment of hepatic lymphorrhea by percutaneous transhepatic lymphangiography followed by sclerotherapy using OK-432. Surg Case Rep 2019; 5 (01) 203-208
  • 31 Matsumoto S, Mori H, Tada I. Successful demonstration of post-operative lymphatic fistula by percutaneous transhepatic lymphography. Clin Radiol 2000; 55 (06) 485-486
  • 32 Parrish CR, McCray S. When chyle leaks: nutrition management options. Pract Gastroenterol 2004; 28: 60-76
  • 33 Baiocchi G, Faloppa CC, Araujo RLC. , et al. Chylous ascites in gynecologic malignancies: cases report and literature review. Arch Gynecol Obstet 2010; 281 (04) 677-681
  • 34 Shah SS, Ahmed K, Smith R, Mallina R, Akhbari P, Khan MS. Chylous ascites following radical nephrectomy: a case report. J Med Case Reports 2008; 2: 3
  • 35 Kinney TB, Ferrara SL, Miller FJ, Roberts AC, Hassanein T. Transjugular intrahepatic portosystemic shunt creation as treatment for refractory chylous ascites and chylothorax in a patient with cirrhosis. J Vasc Interv Radiol 2004; 15 (1, Pt 1): 85-89
  • 36 Tsauo J, Shin JH, Han K. , et al. Transjugular intrahepatic portosystemic shunt for the treatment of chylothorax and chylous ascites in cirrhosis: a case report and systematic review of the literature. J Vasc Interv Radiol 2016; 27 (01) 112-116
  • 37 Weber CN, Nadolski GJ, White SB. , et al. Long-term patency and clinical analysis of expanded polytetrafluoroethylene-covered transjugular intrahepatic portosystemic shunt stent grafts. J Vasc Interv Radiol 2015; 26 (09) 1257-1265 , quiz 1265
  • 38 Sugawara S, Sone M, Arai Y. , et al. Radiological insertion of peritoneovenous shunting for malignant ascites: a retrospective multicenter study. Cardiovasc Intervent Radiol 2011; 34: 980-988
  • 39 Makino Y, Shimanuki Y, Fujiwara N. , et al. Peritoneovenous shunting for intractable chylous ascites complicated with lymphangioleiomyomatosis. Intern Med 2008; 47 (04) 281-285
  • 40 Yarmohammadi H, Brody LA, Erinjeri JP. , et al. Therapeutic application of percutaneous peritoneouvenous (Denver) shunt in treating chylous ascites in cancer patients. J Vasc Interv Radiol 2016; 27 (05) 665-673
  • 41 White MA, Agle SC, Padia RK, Zervos EE. Denver peritoneovenous shunts for the management of malignant ascites: a review of the literature in the post LeVeen Era. Am Surg 2011; 77 (08) 1070-1075
  • 42 Cope C. Percutaneous thoracic duct cannulation: feasibility study in swine. J Vasc Interv Radiol 1995; 6 (04) 559-564
  • 43 Cope C, Kaiser LR. Management of unremitting chylothorax by percutaneous embolization and blockage of retroperitoneal lymphatic vessels in 42 patients. J Vasc Interv Radiol 2002; 13 (11) 1139-1148
  • 44 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 (03) 584-589 , discussion 589–590
  • 45 Yannes M, Shin D, McCluskey K, Varma R, Santos E. Comparative analysis of intranodal lymphangiography with percutaneous intervention for postsurgical chylous effusions. J Vasc Interv Radiol 2017; 28 (05) 704-711
  • 46 Hur S, Shin JH, Lee IJ. , et al. Early experience in the management of postoperative lymphatic leakage using lipiodol lymphangiography and adjunctive glue embolization. J Vasc Interv Radiol 2016; 27 (08) 1177-1186.e1
  • 47 Majdalany BS, El-Haddad G. Contemporary lymphatic interventions for post-operative lymphatic leaks. Transl Androl Urol 2020; 9 (Suppl. 01) S104-S113
  • 48 Ching KC, Santos E, McCluskey K, Jeyabalan G. CT-guided injection of N-butyl cyanoacrylate glue for treatment of chylous leak after aorto-mesenteric bypass. Cardiovasc Intervent Radiol 2014; 37 (04) 1103-1106
  • 49 Kortes N, Radeleff B, Sommer CM. , et al. Therapeutic lymphangiography and CT-guided sclerotherapy for the treatment of refractory lymphatic leakage. J Vasc Interv Radiol 2014; 25 (01) 127-132
  • 50 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 2015; 21 (05) 419-422
  • 51 Sanampudi S, Krohmer S, Raissi D. Direct percutaneous embolization of intestinal lymphatic trunk for chylous ascites management following liver transplant. Radiol Case Rep 2019; 14 (05) 608-612
  • 52 Lee H, Kim SJ, Hur S. , et al. The feasibility of mesenteric intranodal lymphangiography: its clinical application for refractory postoperative chylous ascites. J Vasc Interv Radiol 2018; 29 (09) 1290-1292
  • 53 Chick JFB, VanBelkum A, Yu V. , et al. Balloon retrograde abdominal lymphangiography and embolization for opacification and treatment of abdominal chylous leakage. J Vasc Interv Radiol 2017; 28 (04) 616-618
  • 54 Kariya S, Nakatani M, Ono Y. , et al. Percutaneous balloon plasty for thoracic duct occlusion in a patient with chylothorax and chylous ascites. Cardiovasc Intervent Radiol 2019; 42 (05) 779-783
  • 55 Soga S, Suyama Y, Shinmoto H. Balloon-occluded retrograde glue embolization for intractable lymphorrhea from bilateral iliac lymphatics following surgery for rectal cancer. Radiol Case Rep 2020; 15 (04) 371-374
  • 56 Kariya S, Nakatani M, Ueno Y. , et al. Transvenous retrograde thoracic ductography: initial experience with 13 consecutive cases. Cardiovasc Intervent Radiol 2018; 41 (03) 406-414
  • 57 Yang DM, Jung DH, Kim H. , et al. Retroperitoneal cystic masses: CT, clinical, and pathologic findings and literature review. Radiographics 2004; 24 (05) 1353-1365
  • 58 Karcaaltincaba M, Akhan O. Radiologic imaging and percutaneous treatment of pelvic lymphocele. Eur J Radiol 2005; 55 (03) 340-354
  • 59 Lee Y-N, Wang KL, Lin M-H. , et al. Radical hysterectomy with pelvic lymph node dissection for treatment of cervical cancer: a clinical review of 954 cases. Gynecol Oncol 1989; 32 (02) 135-142
  • 60 Heidenreich A, Pfister D. Retroperitoneal lymphadenectomy and resection for testicular cancer: an update on best practice. Ther Adv Urol 2012; 4 (04) 187-205
  • 61 Briganti A, Blute ML, Eastham JH. , et al. Pelvic lymph node dissection in prostate cancer. Eur Urol 2009; 55 (06) 1251-1265
  • 62 Lucewicz A, Wong G, Lam VWT. , et al. Management of primary symptomatic lymphocele after kidney transplantation: a systematic review. Transplantation 2011; 92 (06) 663-673
  • 63 Tsaur I, Thomas C. Risk factors, complications and management of lymphocele formation after radical prostatectomy: a mini-review. Int J Urol 2019; 26 (07) 711-716
  • 64 Livingston WD, Confer DJ, Smith RB. Large lymphoceles resulting from retroperitoneal lymphadenectomy. J Urol 1980; 124 (04) 543-546
  • 65 Gill IS, Hodge EE, Munch LC, Goldfarb DA, Novick AC, Lucas BA. Transperitoneal marsupialization of lymphoceles: a comparison of laparoscopic and open techniques. J Urol 1995; 153 (3, Pt 1): 706-711
  • 66 Kim JK, Jeong YY, Kim YH, Kim YC, Kang HK, Choi HS. Postoperative pelvic lymphocele: treatment with simple percutaneous catheter drainage. Radiology 1999; 212 (02) 390-394
  • 67 Mahrer A, Ramchandani P, Trerotola SO, Shlansky-Goldberg RD, Itkin M. Sclerotherapy in the management of postoperative lymphocele. J Vasc Interv Radiol 2010; 21 (07) 1050-1053
  • 68 Smolock AR, Nadolski G, Itkin M. Intranodal glue embolization for the management of postsurgical groin lymphocele and lymphorrhea. J Vasc Interv Radiol 2018; 29 (10) 1462-1465
  • 69 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. Cardiovasc Intervent Radiol 2019; 42 (06) 873-879
  • 70 Ferguson JH, MacClure JG. Lymphocele following lymphadenectomy. Am J Obstet Gynecol 1961;82:783–92
  • 71 Horovitz D, Lu X, Feng C, Messing EM, Joseph JV. Rate of symptomatic lymphocele formation after extraperitoneal vs transperitoneal robot-assisted radical prostatectomy and bilateral pelvic lymphadenectomy. J Endourol 2017; 31 (10) 1037-1043
  • 72 Conte M, Panici PB, Guariglia L, Scambia G, Greggi S, Mancuso S. Pelvic lymphocele following radical para-aortic and pelvic lymphadenectomy for cervical carcinoma: incidence rate and percutaneous management. Obstet Gynecol 1990; 76 (02) 268-271
  • 73 Hey HWD, Wong KL, Gatam AR, Lim JL, Wong HK. Delayed lymphocele formation following lateral lumbar interbody fusion of the spine. Eur Spine J 2017; 26 (Suppl. 01) 36-41
  • 74 Fox JA, Rathbun SR, Husmann DA. Development of late, symptomatic abdominopelvic lymphoceles more than 10 years following pediatric reconstructive urologic procedures. J Pediatr Urol 2011; 7 (03) 383-388
  • 75 Hazır B, Haberal HB, Akıncı D, Akdoğan B. An unusual localization of seven months delayed pelvic lymphocele following radical retropubic prostatectomy: Case report and literature review. Int J Surg Case Rep 2018; 44: 181-184
  • 76 Glass LL, Cockett ATK. Lymphoceles: diagnosis and management in urologic patients. Urology 1998; 51 (5A, Suppl): 135-140
  • 77 Yoo B, Ahn H, Kim M. , et al. Nomogram predicting risk of lymphocele in gynecologic cancer patients undergoing pelvic lymph node dissection. Obstet Gynecol Sci 2017; 60 (05) 440-448
  • 78 Sieber PR, Rommel FM, Agusta VE. , et al. Is heparin contraindicated in pelvic lymphadenectomy and radical prostatectomy?. J Urol 1997; 158 (3, Pt 1): 869-871
  • 79 Naselli A, Andreatta R, Introini C, Fontana V, Puppo P. Predictors of symptomatic lymphocele after lymph node excision and radical prostatectomy. Urology 2010; 75 (03) 630-635
  • 80 Ochiai K, Kaneko M, Nozawa H. , et al. Incidence of and risk factors for lymphocele formation after lateral pelvic lymph node dissection for rectal cancer: a retrospective study. Colorectal Dis 2020; 22 (02) 161-169
  • 81 Ranghino A, Segoloni GP, Lasaponara F, Biancone L. Lymphatic disorders after renal transplantation: new insights for an old complication. Clin Kidney J 2015; 8 (05) 615-622
  • 82 Weinberger V, Fischerova D, Semeradova I, Slama J, Cibula D, Zikan M. Ultrasound characteristics of a symptomatic and asymptomatic lymphocele after pelvic and/or paraaortic lymphadenectomy. Taiwan J Obstet Gynecol 2019; 58 (02) 266-272
  • 83 Lohrmann C, Felmerer G, Speck O, Keck T, Foeldi E, Langer M. Postoperative lymphoceles: detection with high-resolution MR lymphangiography. J Vasc Interv Radiol 2006; 17 (06) 1057-1062
  • 84 Guermazi A, Brice P, Hennequin C, Sarfati E. Lymphography: an old technique retains its usefulness. Radiographics 2003; 23 (06) 1541-1558 , discussion 1559–1560
  • 85 Kim HY, Kim JW, Kim SH, Kim YT, Kim JH. An analysis of the risk factors and management of lymphocele after pelvic lymphadenectomy in patients with gynecologic malignancies. Cancer Res Treat 2004; 36 (06) 377-383
  • 86 Recio FO, Ghamande S, Hempling RE, Piver MS. Effective management of pelvic lymphocysts by laparoscopic marsupialization. JSLS 1999; 3 (02) 97-102
  • 87 vanSonnenberg E, Wittich GR, Casola G. , et al. Lymphoceles: imaging characteristics and percutaneous management. Radiology 1986; 161 (03) 593-596
  • 88 Kim Y, Jeon GS, Choi SY, Kim MD, Lee SJ. Evaluation of sclerotherapy for the treatment of infected postoperative lymphocele. Taiwan J Obstet Gynecol 2017; 56 (04) 477-481
  • 89 Klode J, Klötgen K, Körber A, Schadendorf D, Dissemond J. Polidocanol foam sclerotherapy is a new and effective treatment for post-operative lymphorrhea and lymphocele. J Eur Acad Dermatol Venereol 2010; 24 (08) 904-909
  • 90 Kerlan Jr RK, LaBerge JM, Gordon RL, Ring EJ. Bleomycin sclerosis of pelvic lymphoceles. J Vasc Interv Radiol 1997; 8 (05) 885-887