Direct Intranodal Lymphangiography for Recurrent Chylous Ascites Following Liver-Kidney Transplantation

This is the authors' abstract. We don't add key points for this paper.

Lymphangiography (LAG) has been proven to be an extremely beneficial diagnostic tool, and for lymphatic leaks, it can also be used as a therapeutic intervention and can even allow extensive surgery to be avoided.1-3 In this report, we describe a case in which direct intranodal LAG was used as a definitive treatment for persistent chylous ascites after liver-kidney transplantation. Our case involved a 69-year-old male who had undergone transplantation for nonalcoholic steatohepatitis–induced cirrhosis and end-stage renal disease secondary to diabetes. Two months after the operation, he developed ascites. Doppler ultrasound was performed to rule out outflow or portal vein obstructions. Large-volume paracentesis (LVP) of 5 to 6 L was performed every 2 weeks. Elevated triglyceride levels were found in the fluid (up to 600 mg/dL), and they were consistent with chylous ascites. The patient was started on total parenteral nutrition and took nothing by mouth for several days. This resulted in clinical improvement, and his need for paracentesis decreased substantially. However, shortly after the discontinuation of total parenteral nutrition, the ascites returned. Octreotide was started, and total parenteral nutrition was resumed; his fat intake was limited to medium-chain triglycerides. Frequent LVPs were still required every several weeks. To localize the site of the lymphatic leak, nuclear lymphoscintigraphy was performed with technetium-99m sulfur colloid. Fused single-photon emission computed tomography revealed extravasation behind the right external iliac vein. Under ultrasound guidance, a right groin lymph node was accessed with a spinal needle. Three cubic centimeters of Omnipaque was injected; this demonstrated the opacification of a single dominant lymphatic channel, which extended into the patient's pelvis, and identified the leak. Eight cubic centimeters of Lipiodol Ultra-Fluide was injected to further delineate the area and potentially treat the leak (Fig. 1). Delayed imaging at 1 hour did not reveal any further progression of the Lipiodol beyond the area of leakage. At 18 hours, residual Lipiodol remained around the location of the lymphatic leak at the level of the right external iliac vein, but there was no extension into the patient's paracaval or para-aortic lymphatics (Fig. 2). Fluoroscopically captured image of a transnodal injection of Lipiodol. Lipiodol can be seen to be tracking within the lumen of the lymphatic channel (white arrow) with extraluminal spilling of Lipiodol at the level of the leak (open arrow). A radiographic image obtained 18 hours after the injection shows persistent Lipiodol outlining the right external iliac vein (white arrow) and a small amount of Lipiodol pooling in the pelvis (open arrow). No Lipiodol can be seen in the more cephalad lymphatic chains. After this procedure, the patient no longer required LVP. The patient remained asymptomatic without clinically evident ascites 20 months after the Lipiodol injection. Chylous ascites may result shortly after abdominal surgery because of the disruption of lymphatic vessels. Chylous ascites has been described as a rare complication of liver transplantation and an even more infrequent complication of renal transplantation. Many persistent cases will resolve with the institution of a high-protein/low-fat diet and the restriction of long-chain triglycerides. A failure to respond to dietary manipulation may require fasting with parenteral nutrition. Octreotide treatment has also been used. Unfortunately, many instances require surgical interventions, which are limited by the inability to precisely identify the site of leak. A Lipiodol injection during LAG has been proposed to act as an embolic agent within the leaking lymphatic vessel and induce a local inflammatory reaction to seal the leak.3 This procedure has been described for diagnosing and treating chylous ascites after various thoracic and intra-abdominal procedures. Kos et al.1 reported 22 patients with lymph leaks who underwent Lipiodol LAG after surgical intervention. They reported the identification of the leak in 75% of the patients, and 55% demonstrated leak closure. Alejandre-Lafont et al.2 reported 43 patients, with lymphatic leakage identified by LAG in 79%. Patients with an ascitic volume < 500 mL/day had higher closure rates than those with high-volume ascites. In our view, ultrasound-guided intranodal LAG with Lipiodol may be recommended as a modality for identifying and treating posttransplant patients with lymphatic leaks for whom conservative therapy has failed. This case was approved for review by the Internal Review Committee. Aaron M. Williams, M.D.1 Thomas M. Seay, M.D.2 Jonathan C. Hundley, M.D.1 Roberto Gedaly, M.D.1 Departments of 1Surgery (Division of Transplantation)