Intrahepatic lymphatic channel sclerotic embolization for treatment of postoperative lymphatic ascites: a report of 3 cases

Back to the Future II-A Comprehensive Update on the Rapidly Evolving Field of Lymphatic Imaging and Interventions

ABSTRACT

Lymphatic imaging and interventional therapies of disorders affecting the lymphatic vascular system have evolved rapidly in recent years. Although x-ray lymphangiography had been all but replaced by the advent of cross-sectional imaging and the scientific focus shifted to lymph node imaging (eg, for detection of metastatic disease), interest in lymph vessel imaging was rekindled by the introduction of lymphatic interventional treatments in the late 1990s. Although x-ray lymphangiography is still the mainstay imaging technique to guide interventional procedures, several other, often less invasive, techniques have been developed more recently to evaluate the lymphatic vascular system and associated pathologies. Especially the introduction of magnetic resonance, and even more recently computed tomography, lymphangiography with water-soluble iodinated contrast agent has furthered our understanding of complex pathophysiological backgrounds of lymphatic diseases. This has led to an improvement of treatment approaches, especially of nontraumatic disorders caused by lymphatic flow abnormalities including plastic bronchitis, protein-losing enteropathy, and nontraumatic chylolymphatic leakages. The therapeutic armamentarium has also constantly grown and diversified in recent years with the introduction of more complex catheter-based and interstitial embolization techniques, lymph vessel stenting, lymphovenous anastomoses, as well as (targeted) medical treatment options. The aim of this article is to review the relevant spectrum of lymphatic disorders with currently available radiological imaging and interventional techniques, as well as the application of these methods in specific, individual clinical situations.

Successful percutaneous transhepatic lymphangiography and embolization for intractable hepatic lymphorrhea after laparoscopic distal gastrectomy: a case report

BACKGROUND

Hepatic lymphorrhea is a rare and serious complication of surgery for digestive tract cancers and is thought to occur as a result of lymph node dissection of the hepatoduodenal ligament. This complication results in the accumulation of lymphatic fluid, which may in turn lead to nutritional disorders, immune deficiency, and circulation insufficiency. However, there is currently no standard strategy for treating this condition.

CASE PRESENTATION

A 49-year-old woman with alcoholic liver damage underwent laparoscopic distal gastrectomy with lymph node dissection for early gastric cancer. Abundant ascites persisted postoperatively, and the fluid was suspected to indicate hepatic lymphorrhea. The patient was re-admitted on postoperative day 26 due to the onset of a brain infarction caused by dehydration. Various conservative treatments for hepatic lymphorrhea were ineffective. She underwent percutaneous transhepatic lymphangiography and embolization on postoperative day 81, with obvious effect. Computed tomography images demonstrated complete disappearance of ascites.

CONCLUSIONS

Postoperative hepatic lymphorrhea is a rare and serious complication of radical surgery for digestive tract cancers. The current case suggests that percutaneous transhepatic lymphangiography and embolization may be a rational treatment option when conservative treatments fail.

Interventional Management of Acquired Lymphatic Disorders

The lymphatic system is a complex network of tissues, vessels, and channels found throughout the body that assists in fluid balance and immunologic function. When the lymphatic system is disrupted related to idiopathic, iatrogenic, or traumatic disorders, lymphatic leaks can result in substantial morbidity and/or mortality. The diagnosis and management of these leaks is challenging. Modern advances in lymphatic imaging and interventional techniques have made radiology critical in the multidisciplinary management of these disorders. The authors provide a review of conventional and clinically relevant variant lymphatic anatomy and recent advances in diagnostic techniques such as MR lymphangiography. A detailed summary of technical factors related to percutaneous lymphangiography and lymphatic intervention is presented, including transpedal and transnodal lymphangiography. Traditional transabdominal access and retrograde access to the central lymph nodes and thoracic duct embolization techniques are outlined. Newer techniques including transhepatic lymphangiography and thoracic duct stent placement are also detailed. For both diagnostic and interventional radiologists, an understanding of lymphatic anatomy and modern diagnostic and interventional techniques is vital to the appropriate treatment of patients with acquired lymphatic disorders. ^©RSNA, 2022.

Percutaneous embolization of hepatic lymphorrhea post-hepatectomy

Abdominal effusion due to hepatic lymphorrhea post-hepatectomy is an extremely rare and complex complication in clinical practice. No standard treatment method has been established for this condition to date. We report a case of complicated intra-abdominal lymphatic leakage in a patient following hepatectomy to treat hepatocellular carcinoma. The patient underwent percutaneous embolization of the hilar hepatic lymphatic system, combined with intensive medical treatment. Percutaneous embolization represents a safe and effective method that should be considered as a first-line treatment for this complication.

Radiological management of postoperative lymphorrhea

PURPOSE

Postoperative lymphorrhea can occur after different surgical procedures and may prolong the hospital stay due to the need for specific treatment. In this work, the therapeutic significance of the radiological management of postoperative lymphorrhea was assessed and illustrated.

METHOD

A standardized search of the literature was performed in PubMed applying the Medical Subject Headings (MeSH) term "lymphangiography." For the review, the inclusion criterion was "studies with original data on Lipiodol-based Conventional Lymphangiography (CL) with subsequent Percutaneous Lymphatic Intervention (PLI)." Different exclusion criteria were defined (e.g., studies with <15 patients). The collected data comprised of clinical background and indications, procedural aspects and types of PLI, and outcomes. In the form of a pictorial essay, each author illustrated a clinical case with CL and/or PLI.

RESULTS

Seven studies (corresponding to evidence level 4 [Oxford Centre for Evidence-Based Medicine]) accounting for 196 patients were included in the synthesis and analysis of data. Preceding surgery resulting in postoperative lymphorrhea included different surgical procedures such as extended oncologic surgery or vascular surgery. Central (e.g., chylothorax) and peripheral (e.g., lymphocele) types of postoperative lymphorrhea with a drainage volume of 100-4000 ml/day underwent CL with subsequent PLI. The intervals between "preceding surgery and CL" and between "CL and PLI" were 2-330 days and 0-5 days, respectively. CL was performed before PLI to visualize the lymphatic pathology (e.g., leakage point or inflow lymph ducts), applying fluoroscopy, radiography, and/or computed tomography (CT). In total, seven different types of PLI were identified: (1) thoracic duct (or thoracic inflow lymph duct) embolization, (2) thoracic duct (or thoracic inflow lymph duct) maceration, (3) leakage point direct embolization, (4) inflow lymph node interstitial embolization, (5) inflow lymph duct (other than thoracic) embolization, (6) inflow lymph duct (other than thoracic) maceration, and (7) transvenous retrograde lymph duct embolization. CL-associated and PLI-associated technical success rates were 97-100% and 89-100%, respectively. The clinical success rate of CL and PLI was 73-95%. CL-associated and PLI-associated major complication rates were 0-3% and 0-5%, respectively. The combined CL- and PLI-associated 30-day mortality rate was 0%, and the overall mortality rate was 3% (corresponding to six patients). In the pictorial essay, the spectrum of CL and/or PLI was illustrated.

CONCLUSION

The radiological management of postoperative lymphorrhea is feasible, safe, and effective. Standardized radiological treatments embedded in an interdisciplinary concept are a step towards improving outcomes.

Refractory Hepatic Lymphorrhea: Percutaneous Transhepatic Lymphangiography and Embolization with n-Butyl-2-Cyanoacrylate Glue

Hepatic lymphorrhea is a leakage from the liver's lymphatic ducts into the abdominal cavity and an extremely rare complication associated with injury of the hepatoduodenal ligament, which can lead to refractory ascites. Hepatic lymphorrhea is constituted by non-chylous ascites and can be visualized by transhepatic lymphangiography instead of pedal or intranodal lymphangiography. To date, only a few successfully treated cases using interventional procedures have been reported. Although n-butyl-2-cyanoacrylate (NBCA) glue is widely used in various cases of vascular embolization and other lymphatic leak treatments, there have been no reports of its use for post-surgical hepatic lymphorrhea. The NBCA glue embolization described in this case report may be one of the treatment options to control the refractory ascites derived from hepatic lymphorrhea.