Successful Treatment of a Refractory Lymphatic Fistula after Laparoscopic Para-Aortic Lymphadenectomy Using Dual Real-Time Lymphangiography with Indocyanine Green and a High-Fat Diet.

INTRODUCTION: Postoperative lymphatic fistula is a relatively rare complication of abdominal and pelvic surgery. Lymphatic fistula is classified based on whether it contains lymphatic ascites with clear lymphatic fluid from the lumbar lymphatic trunks or chylous ascites with milky chyle fluid from the intestinal lymphatic trunk. These two lymphatic trunks eventually converge into the cisterna chyli, which is located at vertebrae T10-L3. In cases of lymphatic fistula following lymphadenectomy in this region, lymphatic leakage from either the intestinal or lumbar lymphatic trunk, or both, should be suspected. Here, we report the successful treatment of a refractory lymphatic fistula after para-aortic lymphadenectomy for rectal cancer by visualizing intestinal lymphatic leakage using enteral high-fat milk and lumbar lymphatic leakage using inguinal intranodal lymphangiography with indocyanine green (ICG).

CASE PRESENTATION: A 57-year-old male developed chylous ascites with elevated triglyceride levels after para-aortic lymphadenectomy. Conservative treatments, including dietary management with fasting, total parenteral nutrition, and administration of octreotide, were ineffective. Although lymphangiography with lipiodol identified lumbar lymphatic leakage, it failed to stop the lymphatic fistula. The intestinal lymphatic leakage site detected by enteral high-fat milk was sutured laparoscopically, and the lumbar lymphatic leakage site was glued with a fibrin sealant patch. However, persistent lymphatic leakage required repeated abdominal paracentesis. Open suturing of the lymphatic leakage site was performed using navigation with ICG and high-fat milk to resolve the lymphatic fistula completely. Lymphatic leakage from the intestinal lymphatic system was detected using enteral high-fat milk and from the lumbar lymphatic trunk using inguinal intranodal lymphangiography with ICG. A total of 5 mL of ICG (1.25 mg/mL) was injected into the inguinal lymph node. ICG leakage was identified at the lumber lymphatic trunk. The leakage site was sutured until the leakage disappeared. Four months after surgery, the ascites disappeared utterly.

CONCLUSIONS: This case demonstrates the efficacy of combining enteral high-fat milk and inguinal intranodal lymphangiography with ICG for accurate detection and differentiation of lymphatic leakage sources. Our dual lymphangiography technique aids in distinguishing leakage from either the intestinal lymphatic or lumbar lymphatic systems, which is critical for the successful treatment of complex lymphatic fistula.