Management of intractable post‐adrenalectomy chylous ascites with microsurgical intra‐abdominal lymphaticovenous anastomosis: A case report and literature review

Abstract

Postoperative chylous ascites is a rare but highly morbid complication following thoracic or abdominal surgeries. Treatment options vary according to different clinical scenarios and facility equipment, but there is no standard guideline. We report a case of 46‐year‐old patient with chylous ascites after left laparoscopic adrenalectomy for metastatic lung cancer. The conservative treatments failed, included diet control, somatostatin provided and intranodal lymphangiography with lipiodol injection. Laparotomy was performed to explore the lymphatic vessel in the retroperitoneal area where a major and several small leaking holes were identified along the thoracic duct. The left gonadal vein was explored and transposed toward the lymphatic vessel. The lymphaticovenous anastomosis (LVA) was done using side (major leaking hole) to end (gonadal vein) fashion. The chylous leakage dropped from 2000 to 200 mL per day gradually within 10 days after LVA, and the patient was discharged uneventfully 30 days after the LVA surgery. He was followed at our clinic during the first postoperative 10 months without recurrent chylous ascites. This case demonstrates that microsurgical intervention with LVA to physiologically drain the chyle can be an optimal treatment for chylous ascites. A literature review was also conducted, and strategic management is proposed.

Lymphatic‐venous anastomosis for the treatment of refractory lymphatic ascites following radiation therapy: A case report

“…In case of postsurgical lymphatic fluid accumulation, a major lymph leakage site may be identifiable; intra-abdominal LVA using the leakage site may be feasible and effective. (Chu et al, 2021;Weissler et al, 2018) However, because our patient had no history of an intraabdominal surgery and the ascites was caused solely by radiation therapy, the peritoneal lymphatic system in our case was considered to be more grossly and diffusely damaged as compared with that in postsurgical cases. Moreover, in our case, the refractory ascites was serous and not chylous, because the irradiation mainly affected the intrapelvic lymphatic system located more distally than the chyle cistern.…”

Contemporary Management of Chylous Ascites after Retroperitoneal Surgery: Development of an Evidence-Based Treatment Algorithm

“…This can be accomplished in the lower extremity or in the retroperitoneal space by anastomosing lymphatic channels to the gonadal vein. 38,39…”

“…This can be accomplished in the lower extremity or in the retroperitoneal space by anastomosing lymphatic channels to the gonadal vein. 38,39 The most reported surgical method to definitively treat CA is surgical exploration and ligation via laparoscopy or laparotomy. Injection of the lower extremity with blue dye may help assist in identifying chylous leakage from the lumbar trunk in the retroperitoneum.…”

Lymphaticovenous anastomosis for treatment of refractory chylous ascites: A case report

“…Here, 99m Tc accumulation disappeared after LVA, indicating effective treatment. Lymphangiography using lipiodol can identify leakage sites and treat lymphatic leaks, although the embolizing effect of lipiodol might cause lymphedema leading to CA recurrence (Al‐Busafi et al, 2014; Bhardwaj et al, 2018; Chu et al, 2021). Here, lymphoscintigraphy and lymphangiography with lipiodol did not identify the leakage site.…”