Preliminary Experience with Intranodal Lymphangiography with Lipiodol for Postoperative Persistent Chylous Ascites

Objective: Chylous ascites due to lymphatic leakage post abdominal surgeries is a rare but severe complication whose incidence is increasing due to extended resections and lymph node (LN) dissections. Prolonged chyle leak can lead to infections, delayed wound healing, and severe malnutrition in patients.

Material and Methods: A 64-year-old male patient underwent radical nephrectomy for right renal cell carcinoma with lymphadenectomy (aortocaval LNs). Postoperatively, he developed chylous ascites (elevated fluid triglyceride levels > 600 mg/dL) draining ~3–4 L/day through the abdominal drain. Conservative treatment including total parenteral nutrition/prolonged medium chain triglycerides diet and Octreotide injections failed and chyle leak continued (Van der Gaag Grade C). The patient was then offered lipiodol lymphangiography (LAG) as an alternative.

Under ultrasound guidance, intranodal LAG was done with 10 cc of lipiodol (Guerbet, United States) from a suitable right inguinal LN and sequential fluoroscopic images were taken. The site of leakage was identified in the left para-aortic region with dense lipiodol deposition at that site. At 24 hours, residual lipiodol remained at the location of lymphatic leak and ascites became clear with reduced output.

Results: Post LAG, the daily chylous ascites output was reduced to 1 L/day on day 1 with a gradual decline to 0 output over 6 days. Ascitic drain was subsequently removed and the patient is asymptomatic at two months follow-up.

Conclusion: Intranodal LAG with lipiodol is an effective method for identification and treatment of lymphatic leaks when conservative treatment has failed and can be curative in itself, thus avoiding extensive surgeries.