Abstract No. 242 Refractory Lymphatic Ascites After Liver Transplantation: Identification of the Underlying Mechanism of Ascites Permits Successful Percutaneous Treatment

Liver transplantation is a life-saving but inherently invasive surgery requiring retroperitoneal resection and multiple structural anastomoses. Approximately 5% of patients develop intractable ascites after liver transplantation. This study describes the diagnosis and treatment of lymphatic ascites in patients post liver transplantation that is refractory to conservative therapy. Review of internal prospectively collected database was performed to identify patients who received interventions for refractory ascites after liver transplantation. Patient demographics, baseline pathological characteristics, imaging findings, procedural details, and follow-up information was collected. Database review identified 9 patients (average 32y, F:M/7:2) after orthotopic liver or split orthotopic liver transplantation. 5/9 patients presented with chylous ascites (CA) characterized by elevated triglycerides (850.8 ± 603.5 mg/dL) in the fluid, and 4/9 with liver lymphorrhea characterized by elevated albumin in the ascites (SAAG< 1 and ∼90% of plasma level). In 3/5 patients with CA, intranodal lymphangiography demonstrated obstruction of the central lymphatic system. The mesenteric lymphatics were then embolized with either glue or Lipiodol. The fourth patient with CA demonstrated stenosis of the portal vein anastomosis on CT that was balloon dilated using a transjugular approach. The fifth patient with CA was diagnosed with narrowing of the hepatic vein anastomosis and underwent TIPS. All 5 patients with CA achieved resolution at a median of 37 days after intervention (IQR 31), with a mean follow-up of 9.2±6.9 months. In 4/4 patients presenting with liver lymphorrhea, liver lymphangiography demonstrated contrast extravasation into the peritoneum and underwent transhepatic lymphatic embolization with either glue or Lipiodol. All 4 patients achieved resolution at a median of 14 days after intervention (IQR 10), with a mean follow-up of 17.8±3.9 months. Three mechanisms of post-transplantation lymphatic ascites were identified: (1) Portal hypertension due to the mechanical iatrogenic obstruction; (2) Obstruction of the central lymphatic system, resulting in congestion of the mesenteric lymphatic system and mesenteric lymphatic leak; and (3) Liver lymphorrhea. Identification of the mechanism of ascites allowed for successful percutaneous treatment in all patients.