Diagnostic imaging, therapeutic interventions and suggestions for thoracic duct congestion in postoperative hepatic lymphorrhea: a retrospective analysis of 20 cases.

Objective: To retrospectively evaluate thoracic duct (TD) congestion in hepatic lymphorrhea (HL) and propose treatment suggestions.

Methods: Retrospectively analyze cases of postoperative HL admitted from August 2007 to November 2023. Twenty cases were enrolled and followed up. The medical history, ascites characteristics, lymphoscintigraphy, direct lymphangiography, and other clinical data were reviewed.

Results: Twenty patients with ascites after cholecystectomy or radical gastrectomy were included. There were 15 patients with cirrhosis and 5 patients with hepatitis. Ascites were light yellow even if the patients had a non-low-fat diet. Triglyceride level mean of ascites was 0.61 ± 0.20 mmol/L. There were 94.1% (16/17) of patients whose ascitic cholesterol ≥ 45 mg/dL or SAAG < 11.0 g/L. Mild abdominal radioactivity was shown in 89.5% (17/19) patients. Left subclavian-jugular venous angle radioactivity was observed in 84.2% (16/19) patients. In 10% (2/20) cases, lipiodol presenting as oil droplets traveled upwards quickly and flowed into the vein rapidly. In 90% (18/20) cases, tortuous and dilated thoracic duct, stagnant lipiodol, and poor flow into the vein were demonstrated. One patient refused treatment and died soon. By thoracic duct outlet reconstruction combined with other treatments, 16 patients were cured and the ascites of another 3 patients were controlled.

Conclusions: TD congestion and elevated lymphatic pressure could be caused by increased lymph flow and TD outlet stenosis. TD decompression by outlet reconstruction may be an alternative approach to HL.