Lymphatic leakage seriously affects the prognosis of patients and delays further treatment [12-16]. Janco et al. described that surgical treatment is helpful in avoiding metabolic complications, and ligation or suture of the leakage site is 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 embolisation was originally proposed by Cope et al. . The relevant literature notes that the effective rates of lymphangiography and embolisation for postoperative lymphatic leakage are 56% and 86%, respectively; thus the procedures 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 our study, drainage volume decreased significantly in three patients and drainage gradually disappeared in two patients. We saw poor results in the remaining two patients. One of these 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, another operation was risky. Ultrasound-guided intranodal lymphangiography and embolisation were performed after interdisciplinary consultation. During the operation, iodised oil leakage accumulated on the right side of the abdomen (Figure 2B, C). After the contrast medium was flushed out of the iodised oil, a 1:3 iodised oil NBCA mixture was used for lymphatic leakage embolisation. 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 iodised oil diluent was mixed evenly at a ratio of 1:2 . In our study, NBCA iodised 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 iodised oil to the aggregation site before embolisation 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 embolisation. Kim et al noted that in view of the well-known serious mortality and incidence of untreated chylothorax, lymphatic embolisation 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 key to the success of the operation. The incidence of complications in the study was 28.57% (2/7); all complications were mild and controllable, including one case of chronic diarrhoea and one case of puncture site infection; all complications improved after treatment. Another case of diarrhoea in our study was considered to be caused by other factors. After a follow-up of two 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, iodised oil embolisation risks aggravating a pulmonary embolism or causing a cerebral embolism. Although the incidence of such complications is low, they are fatal. Such patients were outside the scope of this study .
The sample size of this study was limited, because postoperative lymphatic leakage is a rare condition. However, this case series clearly demonstrates the feasibility of ultrasound-guided lymph node angiography and lymphatic embolization as a therapeutic option especially for elderly cancer patients who cannot easily tolerate surgery again. The efficacy and safety of this technique needs to be validated in larger prospective trials.