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

Abstract

Postoperative hepatic lymphorrhea is extremely rare and there is no standard treatment for this condition. We report the cases of 3 men, 32-, 56-, and 37-year-old, with postoperative hepatic lymphorrhea, which was refractory to conservative treatment. Transhepatic lymphangiography allowed locating the lymphatic leak and treating it with hepatic lymphatic vessels injection of foam sclerotic agent. This technique seems efficient and safe.

Percutaneous embolization of hepatic lymphorrhea post-hepatectomy

“…Abdominal lymphatic leakage has only been previously described by authors due to damage to the thoracic duct long ago, and other causes of hepatic lymphatic leakage reported in the literature include damage to the hepatoduodenal ligament [2] . Lymphatic leakage can occur following surgery, such as extrahepatic cholangiocarcinoma resection [2] , liver transplant [3] , gastrectomy with nearby lymph node removal [ 4 , 7 ], or pancreatectomy [8] . Another study reported lymphatic leakage following hepatectomy [5] .…”

“…A diagnosis of intra-abdominal lymphatic fistula can easily be determined through the use of laboratory tests and imaging studies to exclude other causes of peritoneal effusion, such as biliary fistula, exudate effusion due to peritoneal metastases, tuberculosis, and transudative effusion [ 3 , 4 ]. In this case, the patient had peritoneal fluid characterized by a high protein concentration (23.8 g/l), which is similar to the serum concentration, in addition to low triglycerides.…”

“…MRI lymphangiography was necessary to exclude lesions from the lumbar trunk and thoracic duct. A diagnosis of lymphatic fistula from the liver is currently made through the direct needle puncture to hepatic lymphatic branches and the injection of contrast material to determine the leakage position [ 1 , 4 ]. In our case, the anatomy had altered somewhat following the hepatectomy, which increased the difficulty of accurately determining the needle puncture position.…”

“…Under the guidance of ultrasound and digital subtraction angiography, contrast injection can be used to determine the location of leakage into the peritoneal cavity, and these branches can be occluded using embolization material. The embolization materials that can be used include Histoacryl (n-butyl 2- cyanoacrylate) diluted with Lipiodol [1] , lauromacrogol (Aetoxisclerol) [4] , or OK-432 [2] . In our case report, we opted to use a Histoacryl/Lipiodol mixture at a 1:8 ratio because the lymphatic branches in the liver are very small.…”

“…Injury to the liver lymphatic system can occur following major liver surgery, such as hepatectomy or liver transplant. To date, hepatic lymphorrhea has only been described in a number of case reports [2] , [3] , [4] , [5] , and diagnosis is typically based on the clinical presentation of abdominal effusion and laboratory testing of the fluid composition, which often features a high protein concentration equivalent to that of serum [6] . Imaging diagnosis is based on direct needle puncture with contrast injection to visualize the lymphatic route and the fistula, followed by the injection of embolization material to block the injured lymphatic branches.…”