Successful treatment of refractory hepatic lymphorrhea after gastrectomy for early gastric cancer, using surgical ligation and subsequent OK-432 (Picibanil) sclerotherapy

Abstract

resulting from probable lymphatic duct injuries during lymph node dissection for a gastric malignancy. Gastrectomy with lymph node dissection is performed acceptably in most Japanese institutions; however, lymphorrhea is frequently encountered after gastric surgery, although the postoperative lymphatic leakage generally stops spontaneously without treatment. There is, though, little information about a standard treatment for postoperative lymphorrhea, which is highly refractory to any conventional medical treatments such as cessation of oral intake, total parenteral nutrition (TPN) management, diuretic therapy, intravenous reinfusion of ascites, or therapeutic paracentesis.Here, we present a case of intractable lymphorrhea in a patient who was successfully treated with surgical lymph vessel ligation, and subsequent OK-432 (Picibanil; Chugai Pharmaceutical, Tokyo, Japan) sclerotherapy. Additionally, we review the present case and the 17 previous reports noted above, and discuss management options. Case reportA 66-year-old man was referred to our department for medical treatment for refractory ascites. One year before admission, he had undergone, in our department, a total gastrectomy with lymphadenectomy for early gastric cancer. Because preoperative study showed that the tumor had probably invaded to the submucosal layer, we performed extended lymph node dissection, including the regional lymph nodes and additional lymph nodes, along the common hepatic artery. His postoperative course was uneventful. The final, pathological staging was T1 (SM), N0, H0, P0, M0, stage IA according to the Japanese classification of gastric carcinoma, second edition [23]. He had chronic B-type viral hepatitis, and was non-cirrhotic, but with normal liver function tests. There was no evidence of recurrence on the basis of Abstract Postoperative hepatic lymphorrhea is a very rare complication after abdominal surgery. Hepatic lymphorrhea, not containing chyle, involves an internal lymph fistula between the lymphatic channels toward the cisterna chyli and the peritoneal cavity. Over the past 20 years, 17 cases have been reported in Japan. Here, we report a further case, of a patient with successfully treated intractable hepatic lymphorrhea following gastrectomy for early gastric cancer. We review 18 cases, including the present case, with respect to the management of postoperative lymphorrhea refractory to conventional medical treatment.

Successful treatment of hepatic lymphorrhea by percutaneous transhepatic lymphangiography followed by sclerotherapy using OK-432

“…Next, the obstructed area was gradually expanded by multiple injections of OK-432, and after seven injections, the leakage site was finally obstructed. There are a few case reports of hepatic lymphorrhea in the English literature [3][4][5], with approximately 20 cases of hepatic lymphorrhea as a complication of LN dissection in the hepatoduodenal ligament in patients undergoing gastric cancer resection in the Japanese literature [1].…”

“…Postoperative lymphatic leakage is an unusual complication after abdominal surgery, although it may occur after a wide range of surgical procedures [1]. Massive ascites is a frequent manifestation and may cause severe malnutrition, which may require additional treatments.…”

Liver Lymphatic Imaging and Interventions: Resurrection of the Forgotten Knowledge

“…19 Liver lymphorrhea is a condition in which there is a leakage of the liver lymph into the peritoneal cavity, typically after abdominal surgery, which causes the disruption of the liver lymphatic ducts. 20,21 Over the years, it has been a relatively underrecognized condition due to the absence of specific liver lymphatic imaging. Application of liver lymphangiography allows recognition of identification of the leak and embolization treatment (►Fig.…”

Treatment and prevention of lymphorrhea after radical gastrectomy of gastric cancer

“…(Iankin. 2006;Tanaka et al 2004) Lymph node metastases occur during the early stages of gastric cancer, and regional lymphadenectomy is recommended as a part of radical gastrectomy.…”