J Gastrointest Canc DOI 10.1007/s12029-010-9240-2
CASE REPORT
Lymphangiography as a Treatment Method for Chylous Ascites Following Pancreaticoduodenectomy Mathieu D’Hondt & Kristien Foubert & Freddy Penninckx & Raymond Aerts
# Springer Science+Business Media, LLC 2010
Introduction Most common causes of chyle leak include neoplastic, cirrhosis and infections of inflammatory aetiologies [1]. Chyle leaks are also a recognised but rarely reported complication following abdominal and retroperitoneal surgery. The preponderance of reports on chyle leak as a postoperative complication has included patients who underwent retroperitoneal lymph node dissection, distal splenorenal shunts, abdominal aortic aneurysm repair or liver transplantation. The overall incidence of chyle leak remains poorly defined. Assumpcao et al. reported an overall incidence of chyle leakage following pancreatic surgery of 1.3%. However, the incidence was highest in patients who underwent pancreaticoduodenectomy (1.8%) [1]. This may be due to the close proximity of the cisterna chyli to the head of the pancreas [2]. We herein report the case of a 62-year-old male who developed massive chylous ascites (4–6 L/day) after pylorus-preserving pancreaticoduodenectomy successfully treated with lymphangiography.
Methods A 62-year-old male with familial adenomatous polyposis had undergone a total colectomy 15 years ago. Recently, an M. D’Hondt : K. Foubert : F. Penninckx : R. Aerts Department of Digestive Surgery, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium M. D’Hondt (*) 467 Rue Garneau, H2j1C9 Montréal, QC, Canada e-mail:
[email protected]
endoscopic retrograde cholangiopancreatography with ampullectomy was performed because a periampullary polyp had been diagnosed. A second polyp of just below the ampulla of Vater was also resected. Anatomopathology of this polyp revealed an adenocarcinoma. A pylorus-preserving pancreaticoduodenectomy was performed. After removal of the drain, the patient developed massive ascites (with a maximum of 6 L/day). For this reason, a peritoneovenous (peritoneojugular) shunt or Denver shunt was placed. One month later, a new Denver shunt was placed because of thrombosis of the first shunt. Three months post-operation, the general condition of the patient deteriorated. Biochemical findings showed dehydration with prerenal renal failure and hypoalbuminaemia. Clinical evaluation showed a relapse of massive ascites confirmed by ultrasound. Several percutaneous drains had to be placed during the following months. Finally, 6 months post-operation, a lymphangiography was performed in an attempt to seal the lymphoperitoneal fistula. First, 2.5 mL of indigocarmine, a dye that may stain the lymphatic vessels, was injected into the first web space of the left foot. Thirty minutes later, linear cut-down was performed on the dorsum of the foot below the ankle and the lymphatic vessel was isolated (Fig. 1). After cannulation of the lymphatic vessel using a 30-gauge needle, 6 mL of iodised oil (lipiodol) was injected at a rate of 0.1 mL/min.
Results Roentgenogram obtained the day after the procedure showed no leakage of the lymphatic vessel. Furthermore, the volume of drained fluid gradually decreased and was finally (after 5 days) reduced to zero (Fig. 2). Until now, 12 months after lymphangiography, no recurrence of chylous ascites has been described and the patient is doing well.
J Gastrointest Canc
Fig. 1 Indigocarmine is injected into the first web space of the left foot. Thirty minutes later, a linear cut-down was performed on the dorsum of the foot below the ankle and the lymphatic vessel was isolated and cannulated
Discussion Chylous ascites is a rare complication after retroperitoneal surgery. Most cases of postoperative chylous ascites heal with conservative therapy such as therapeutic paracentesis, a high-protein, low-fat, medium-chain triglyceride diet and
Fig. 2 Evolution of albumin level, amount of drained ascites and body weight. Lymphangiography performed on July 1 (arrow)
total parenteral nutrition. Chyle leakage can be life threatening because of significant loss of fluid, plasma protein, fats and immunoregulatory lymphocytes [3], and exhibits clinical features of severe malnutrition, hyponatraemia, acidosis, hypocalcaemia and susceptibility to infection. Therefore, mortality is high in patients with uncontrolled or untreated chyle leakage. Surgical treatment such as surgical closure of the lymphoperitoneal fistula and creation of peritoneovenous fistula has been performed. Previously, lymphangiography has been the method of choice for imaging the lymph nodes and lymphatic vessels. Nowadays, the use of conventional diagnostic lymphangiography has become much less frequent since improvements have been made in the diagnostic ability of CT imaging and MRI. However, lymphaniography remains a valuable tool for the detection of various chyle leakages. Recently, Yamagami et al. reported a case of chylous ascites occurring after retroperitoneal lymphadenectomy that was refractory to conservative therapy, but healed spontaneously after lymphangiography [4]. Later, the same group published a case series [5]. The speculated mechanism of attenuation of chyle leakage is that lipiodol infused during lymphangiography accumulates at the point of leakage outside the lymphatic vessel. A regional inflammatory reaction occurs in the soft tissue adjacent to the area of lipiodol retention which seals
J Gastrointest Canc
the lymphatic vessel. Matsumoto et al. performed pedal lymphangiography in nine patients with various chyle leakages refractory to conservative treatment [5]. The daily amount of drainage began to decrease the day after lymphangiography in 78% of patients. Lymphatic leakage finally stopped by continuing conservative treatment, thus avoiding surgical reintervention in 89% of patients. No cases had recurrence of chyle leakage during follow-up (1–54 months). In our patient, chyle leakage was probably located at a smaller lymphatic vessel and not at the large cysterna chyli since no chyle leakage could be seen on the first roentgenogram while chylous ascites still drained through the percutaneous drain. In conclusion, lymphangiography is effective not only for diagnosis and identification of postoperative chyle leaks but can be used as a therapeutic approach in patients with chylous ascites refractory to conservative treatment. However, further research and larger studies are necessary to obtain conclusive information about the
effectiveness of lymphangiography in the treatment of chyle leakage.
References 1. 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. 2. Masanur MA, Batulla N, Azam MO, Heaton N, Rela M. Chylous ascites after pancreatico-duodenectomy cholongiocarcinoma xenografts in nude mice. Hepatobiliary Pancreat Dis Int. 2007;6:416–9. 3. Merrigan BA, Winter DC, O’Sullivan GC. Chylothorax. Br J Surg. 1997;84:15–20. 4. Yamagami T, Masunami T, Kato T, Tanaka O, Hirota T, Nomoto T, et al. Case report: spontaneous healing of chyle leakage after lymphangiography. Br J Radiol. 2005;78:854–7. 5. 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. 2009;82:286–90.
