Indocyanine green lymphography as a method for the diagnostics and management of a hylous ascitis. Clinical case

Abstract

Chylous ascites is an uncommon complication following invasive procedures, occurring in fewer than 5% of cases. Most patients with low output lymphorrhea respond favourably to conservative management. However, in cases of persistent lymphatic leakage, surgical intervention may be warranted.

Case presentation. A 42‑year‑old male developed lymphorrhea following ultrasound‑guided percutaneous drainage of a large perisplenic hematoma and hemoperitoneum. Despite repeated drainage of ascitic fluid (performed three times) and conservative therapy, including dietary modifications, the patient exhibited persistent chylous ascites that necessitated surgical intervention. A total of five abdominal computed tomography (CT) scans and two magnetic resonance imaging (MRI) studies failed to identify the site of lymphatic leakage. The patient was admitted to Riga East Clinical University Hospital, where additional CT and MRI imaging of the abdomen was performed. Surgical treatment was scheduled. During laparotomy, intraoperative fluorescence lymphography was employed using near‑infrared imaging with indocyanine green (ICG) injection. Lymphatic leakage was identified in the vicinity of the left diaphragmatic crus. Approximately three minutes after paraaortic administration of ICG, intact lymphatic vessels became visible, and within five minutes, the precise site of leakage was localized via fluorescence‑guided extravasation. The leaking lymphatic vessel was coagulated and sealed using a TachoSil^® hemostatic patch. A surgical drain was placed adjacent to the repair site for postoperative monitoring. No recurrence of chylous ascites was observed during a four‑month follow‑up period. Intraoperative identification of lymphatic leakage remains challenging due to the small calibre of lymphatic vessels and the low‑pressure flow of lymph, which is often imperceptible to the unaided eye. Fluorescence‑guided lymphography using ICG significantly enhances intraoperative visualization of compromised lymphatic structures. In cases of refractory chylous ascites, surgical management incorporating this technique appears to be both safe and effective.

Conclusions. This case highlights the successful surgical management of refractory chylous ascites utilizing intraoperative indocyanine green fluorescence lymphography, which enabled precise identification and closure of the lymphatic leakage site.