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CASE REPORT
CT-Guided Intranodal Lymphangiography for PostoperativeChylous Ascites
Masanori Hirata1 • Atsuo Shimizu1 • Shoko Abe1 • Azusa Ichinose1 •
Akira Sugiyama1 • Yusuke Tanino2 • Suguru Watanabe2 • Ryota Nakano2 •
Yoshihiko Kato2 • Toshiyuki Miyahara2 • Yasuhiro Sumi2 • Hiroshi Nakano2
Received: 27 January 2017 / Accepted: 29 March 2017 / Published online: 5 April 2017
� Springer Science+Business Media New York and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2017
Abstract The utility and minimal invasiveness of ultra-
sound-guided intranodal lymphangiography have already
been reported by several researchers. Although ultrasound-
guided intranodal lymphangiography is known to be not
technically difficult in general, a patient’s edematous groin
due to hypoalbuminemia resulting from chylous ascites
made it too challenging to detect and prick the lymph
nodes precisely. This report describes a 71-year-old female
with refractory chylous ascites due to an operation for an
extrahepatic bile duct cancer, who was successfully treated
by computed tomography (CT)-guided intranodal lym-
phangiography. After switching from ultrasound- to CT-
guided lymphangiography, the procedure was successfully
performed, and the refractory chylous ascites was treated.
Keywords Intranodal lymphangiography � Chylousascites � Pylorus-preservingpancreaticoduodenectomy � Chylothorax � Lipiodol
Introduction
Chylous ascites may occur after abdominal surgery as a
result of damage to the intraabdominal lymphatic vessels.
Lymphangiography is known to be both diagnostic and
therapeutic for chylous leakage. Ultrasound (US)-guided
intranodal or inguinal lymphangiography is easier and
more practical than pedal lymphangiography [1]. Never-
theless, thick edematous skin and massive ascites may
hamper the precise detection of inguinal lymph nodes. We
herein report a case of a postoperative chylous ascites
treated by computed tomography (CT)-guided intranodal
& Masanori Hirata
Atsuo Shimizu
Shoko Abe
Azusa Ichinose
Akira Sugiyama
Yusuke Tanino
Suguru Watanabe
Ryota Nakano
Yoshihiko Kato
Toshiyuki Miyahara
Yasuhiro Sumi
Hiroshi Nakano
1 Department of Radiology, Shizuoka Medical Center, 762-1
Nagasawa, Shimizucho, Suntogun, Shizuoka Pref, Japan
2 Department of Surgery, Shizuoka Medical Center, 762-1
Nagasawa, Shimizucho, Suntogun, Shizuoka Pref, Japan
123
Cardiovasc Intervent Radiol (2017) 40:1281–1284
DOI 10.1007/s00270-017-1644-y
lymphangiography, instead of US guided. To our knowl-
edge, this is the first report of CT-guided intranodal lym-
phangiography with a groin puncture.
Case Report
A71-year-oldwomanwithjaundicewasadmittedtoourhospital.She
was diagnosed with extrahepatic bile duct cancer. The stage of the
cancer was T2N1M0. After percutaneous transhepatic biliary drai-
nage, pylorus-preserving pancreaticoduodenectomy was performed.
On postoperative day (POD) 10, her belly was swollen and strained
due to ascites. On POD 15, both legs became edematous. Since the
ascites kept increasing and the levels of serum albumin decreased,
diagnostic abdominal paracentesis was performed on POD 20. A
biochemical examination for ascites revealed chylous ascites. On the
same day, we started to treat her with diuretics by administering a
medium-chain triglyceride through a central venous catheter.
Although conservative treatment was continued, the chylous ascites
worsened (Fig. 1), the level of serum albumin kept decreasing, and
her urine output dropped to\1000 ml per day.
On POD 33, intranodal lymphangiography was per-
formed. US-guided puncture in the bilateral groins was
attempted but unsuccessful, as the patient’s thick edema-
tous skin prevented the precise detection and tapping of the
inguinal lymph nodes. We therefore switched to a CT-
guided puncture methods. An initial CT scan of the
abdomen was performed to identify the bilateral inguinal
lymph nodes, and the size of the targeted lymph nodes was
about 10 mm in width and 13 mm in depth on right and
9 mm in width and 10 mm in depth on left in transverse CT
images. A 23-gauge butterfly needle with a tube connected
to a 2.5-ml syringe, which seemed to be reasonable to
prevent forceful injection by hand and not to give too much
pain when pricked, was then inserted above the node, and
CT was performed again to verify that the needle was
placed right above the lymph node. After confirming that
the head of the needle was positioned correctly, approxi-
mately 1 ml of water-soluble contrast agent (300 mg
iodine/ml Iopamidol, Oypalomin 300; Fuji Pharma, Tokyo,
Japan) was injected as a tester, and CT was performed to
see whether the agent had been injected into the lymph
node. After confirming that the agent had indeed been
successfully injected into the lymph nodes, the oily contrast
media—lipiodol (Lipiodol 480; Guerbet Japan, Tokyo,
Japan)—was slowly injected into the lymph node. For the
right inguinal lymph node, 2 ml of lipiodol was injected
into the center of the lymph node and 1 ml into the caudal
part of the lymph node, and for the left inguinal lymph
node, 2 ml of lipiodol was injected.
Immediately after the injections, CT was performed
again to check whether or not the lymph nodes were
Fig. 1 Plain CT images on
POD 32 showed a swollen belly
due to chylous ascites
Fig. 2 A, B CT images of CT-
guided intranodal
lymphangiography. A 23-gauge
needle was pricked above the
inguinal lymph nodes on both
sides, and lipiodol was injected
1282 M. Hirata et al.: CT-Guided Intranodal Lymphangiography for Postoperative Chylous…
123
enhanced. Although the inguinal lymph nodes and
upstream lymph ducts were enhanced, a small amount of
lipiodol had leaked into the subcutaneous tissues on the
right side, and most of the lipiodol had leaked on the left
side (Fig. 2A, B). It seemed that neither side of the lymph
node nor the upstream lymph ducts had been injected with
a sufficient amount of lipiodol to determine where the
lymph duct was damaged. On the same day, abdominal tap
was performed, and 1500 ml of ascites was drained.
The day following lymphangiography, the patient’s
urine output was[2000 ml a day. We examined chest and
abdominal radiographs to determine how far the contrast
agent had traveled from the inguinal lymph node and found
that it had risen to around the level of L3 (Fig. 3A). A few
days later, the patient began to take meals, her general
condition improved, and her swollen belly subsided
(Fig. 3B). At 16 days after intranodal lymphangiography
(-POD 49), she was discharged from the hospital. She
remained asymptomatic without ascites 6 month after
lymphangiography.
Discussion
The causes of chylous ascites include filariasis, tubercu-
losis, trauma, hepatic cirrhosis, and complications of sur-
gical operation. Patients with chylous ascites may feel
discomfort and have a poor appetite due to abdominal
fullness, even suffering from malnutrition because of the
leakage of lymph fluid.
The methods of conservative managements for chylous
ascites are abdominal paracentesis and drainage, a trial of
low-fat diet with the restriction of long-chain triglycerides
for three to four weeks, and fasting with total parenteral
nutrition. Octreotide treatment is also performed on occa-
sion. However, if these conservative treatments fail,
patients must undergo a surgical ligation of lymphatic
vessels to the thoracic duct while identifying the site of the
lymph leak [2].
Conventional lymphangiography initially required great
precision, as the operator had to inject contrast agents such
as indocyanine green (ICG) into thin, undistinguishable
lymph nodes on the foot [1]. US-guided lymphangiography
requires far less technically proficiency and is less invasive
than the conventional method. In addition, quite a few
reports have described the use of US-guided intranodal
lymphangiography to treat refractory chylothorax or chy-
lous ascites after traumas or surgery [1, 3–6]. We aban-
doned US-guided puncture in the groin due to the lack of
clarity with US images in the present case.
For CT-guided lymphangiography, the patient had to be
exposed to radiation each time CT was performed. In
general, US-guided intranodal lymphangiography should
be considered first, as it does not require radiation expo-
sure. In addition, serious complications of lymphangiog-
raphy using lipiodol, such as cerebral infarction and
pulmonary embolism, have been reported. These compli-
cations seem to be preventable if we carefully consider the
amount of lipiodol to be administered. In the previous
studies, the volume of lipiodol injection needs to be more
than 3 ml in order to detect the chylous leaks but not to
exceed 20 ml to avoid serious complications [7, 8]. With-
out the benefit of fluoroscopic guidance in the present case,
we used water-soluble contrasts agent as a tester so that we
could avert the smallest chance of severe complications
due to the excess amount of lipiodol in the course of the
CT-guided identification of inguinal lymph nodes. In the
present case, total amount of lipiodol injection was 5 ml,
which was almost 1 ml/10 kg, and its rate was approxi-
mately 0.3 ml/min. Both were decided upon referring to
the literature [6, 7]. Complications of lymphangiography
include infection, pain, and lipiodol extravasation into the
soft tissue [9]. In the present case, although the lipiodol
remained under the skin in the groins for several days after
Fig. 3 A, B A plain abdominal radiograph taken on the day following
lymphangiography showed an oval-shaped pooling of the contrast
agent (arrowed) on the level of L3. A CT image of the abdomen
obtained 1 week after intranodal lymphangiography showed the
decrease in ascites
M. Hirata et al.: CT-Guided Intranodal Lymphangiography for Postoperative Chylous… 1283
123
intranodal lymphangiography, the patient did not suffer any
other complications. Subsequently to lymphangiography,
edematous legs improved most likely because hypoalbu-
minemia that had been caused by chylous ascites was
compensated. It has been suggested that lipiodol embolizes
and then induces inflammatory reactions at the point of
lymphatic leakage and thus leads to the closure of the
lymphatic leaks [10, 11]. Having considered the relatively
small amount of the lipiodol injection on both sides of the
lymph nodes and the favorable clinical outcome in this
case, some of the lipiodol that leaked on the left side could
have been absorbed in the lymph node to rise afterward. As
reported by several studies, lymphangiography itself
seemed to have played a therapeutic role in chylous ascites
and also in leg edema in succession [7, 8, 10, 11].
We herein reported a case of a postoperative chylous
ascites treated by CT-guided intranodal lymphangiography.
To our knowledge, this is the first report of CT-guided
intranodal lymphangiography with a groin puncture. CT-
guided intranodal lymphangiography may be a good
alternative and a second choice when US-guided intranodal
lymphangiography cannot be performed.
Acknowledgements Masanori Hirata wish to thank the senior doc-
tors of the Department of Radiology for encouraging me to publish
this case report.
Compliance with Ethical Standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical Approval This article does not contain any studies with
human participants or animals performed by any of the authors.
Informed Consent Informed consent was provided by the patient.
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