A case of chylous ascites caused by reflux from the cisterna chyli to the disrupted common iliac lymphatic vessel: fluoroscopic records during intranodal lymphangiography.

Abstract

A 40-year-old woman underwent laparoscopic common iliac lymphadenectomy for metastasis from rectal cancer. Two weeks after the surgery, she was found to have massive chylous ascites. After failure of conservative treatment, bilateral inguinal intranodal lymphangiography was performed. No definite extravasation was observed while lipiodol injected through the left inguinal node was ascending. When we punctured the right inguinal lymph nodes and started the injection of lipiodol, extravasation of diluted lipiodol was noted at the level of the first sacrum. Careful observation revealed that the ascending lipiodol became diluted in the cisterna chyli, refluxed through the median paraaortic route, leaked from the excised left common iliac lymph vessel, and flowed into the abdominal cavity. Lipiodol used in lymphangiography did not reduce chylous ascites at all. Twenty-seven days after lymphangiography, laparoscopic lymphatic ligation was performed, and the chylous ascites disappeared completely. CT obtained 40 days after surgical repair revealed disappearance of ascites and enlargement of the thoracic duct, which had not been observed on preoperative lymphangiography. Notably, lymphatic reflux from the cisterna chili can occur without obstruction of the thoracic duct and may result in chylous ascites.