Lymphatic leakage seriously affects the prognosis of patients and delays further treatment [11-16]. Janco et al. described that surgical treatment is helpful in avoiding metabolic complications, and ligation or suture of the leakage site was recommended . However, surgical treatment for lymphatic leakage is a more aggressive approach, and it is often difficult for patients with cancer to tolerate another operation after abdominal or pelvic surgery [18, 19].
The technique of lymphatic embolization was originally proposed by Cope et al. . The relevant literature notes that the effective rates of lymphangiography and embolization for postoperative lymphatic leakage are 56% and 86%, respectively, which can be used as alternatives to surgical treatment [21-23].
In this study, the clinical effective rate was 71.43% (5/7), which was consistent with the reports of Matsumoto et al. [21-23]. In the study, the drainage volume decreased significantly in three patients, drainage gradually disappeared in two patients, and the effect was not good in the other two patients. One of the patients was diagnosed with a giant abdominal cystadenoma and underwent surgical resection (Figure 2A). Abdominal distension occurred after the operation in this patient. Combined with the MRI examination results, lymphatic leakage was considered; hence, abdominal puncture drainage was performed, and the daily drainage volume was as high as approximately 1200 ml. Because the patient had high-flow leakage and had previously undergone surgery, there was a risk of reoperation. Ultrasound-guided intranodal lymphangiography and embolization were performed after interdisciplinary consultation. During the operation, iodized oil leakage accumulated on the right side of the abdomen (Figure 2B, C). After the contrast medium was flushed out of the iodized oil, a 1:3 iodized oil NBCA mixture was used for lymphatic leakage embolization. However, there was persistent lymphatic leakage after the operation, with a daily drainage volume of 700 mL, which was lower than before. The patient underwent further surgical treatment one week later.
For patients with poor clinical effects, preoperative lymphangiography can better determine the leakage site, provide an effective reference for surgical treatment, and facilitate the localization and ligation of the target lymphatic vessels during the operation .
It has been reported that the NBCA iodized oil diluent was mixed evenly at a ratio of 1:2 . In our study, the NBCA iodized oil diluent was used and mixed evenly at a ratio of 1:3 to 1:4. We believe that this concentration can provide a long injection time, allowing sufficient advancement of the NBCA glue in the lymphatic networks. In addition, 5% glucose water was used to push the residual iodized oil to the aggregation site before embolization to prevent the mixture from accumulating rapidly in the lymph nodes.
Kim et al retrospectively evaluated the complications of 24 patients who underwent successful lymphatic embolism. Kim et al noted that in view of the well-known serious mortality and incidence of untreated chylothorax, lymphatic embolization may be a feasible option for the treatment of chylothorax.
In our study, ultrasound-guided puncture of inguinal lymph nodes was used. Good ultrasound guidance techniques are keys to the success of the operation. The incidence of complications in the study was 28.57% (2/7); all complications were mild symptoms that could be controlled, including one case of chronic diarrhoea and one case of puncture site infection, all of which improved after symptomatic treatment. Another case of diarrhoea in our study was considered to be caused by other factors. After a follow-up of 2 weeks, no serious complications were found in the patients.
In patients with pulmonary insufficiency (PaO2 lower than 60 mmHg) or with a right-to-left cardiac shunt, iodized oil embolization risks aggravating a pulmonary embolism or causing a cerebral embolism. Although the incidence of such complications is low, these complications are fatal. Such patients were outside the scope of this study .
Postoperative lymphatic leakage is a rare condition, and the number of cases in this study were limited. Since this technique has not yet been popularized, this group of cases included elderly patients with cancer who could not tolerate surgery again, but the technique itself has no age limitation. The efficacy and safety of ultrasound-guided lymph node angiography and lymphatic embolization need to be further verified in more studies.