The Use of Indocyanin Green for Peroperative Diagnostic of Chylous Ascites and Autologous Tissue Glue (Vivostat) for the Treatment

Czech version

Authors: Andrea Zetelová ¹; Ivo Rovný ¹; Zdeněk Kala ¹; Petr Moravčík ¹; Luboš Minář ²
Authors‘ workplace: Chirurgická klinika LF MU a FN Brno 2 Gynekologická klinika FN Brno ¹
Published in: Klin Onkol 2020; 33(2): 145-149
Category: Case Report
doi: https://doi.org/10.14735/amko2020145

Overview

Background: Chylous ascites or chyloperitoneum can be caused by peroperative injury of the lymphatic pathways; the lymph is accumulated in the abdominal cavity. The incidence of chylous ascites varies according to the type of surgery and the extent of the lymphadenectomy. The first choice of treatment is a conservative procedure – total parenteral nutrition or a strict low-fat diet. If this fails, a surgical revision is indicated. However, this is often difficult due to postoperatively altered terrain and the chronic presence of pathological secretion in the abdominal cavity. The application of a fat emulsion or indocyanine green (ICG) to the lymphatic drainage area may help identify the lymph source. Nowadays, ICG is used in various clinical indications, e. g. evaluation of liver function, angiography in ophthalmology, assessment of blood supply to the tissues, search for lymph nodes in oncological surgeries. The advantage of ICG lymphography is the possibility of observing the source of the leak in real time directly during surgical revision.

Case report: A polymorbid 66-year-old patient after radical oncogynaecological surgery with aortopelvic lymphadenectomy was postoperatively complicated by persistent, high-volume chylous ascites, not responding to conservative treatment. Therefore, we performed surgical revision of the abdominal cavity and successful treatment of the leak source using ICG peroperative lymphography and subsequent application of Vivostat autologous tissue glue to this area.

Conclusion: High-volume consistent chylous ascites is not a frequent postoperative complication but it has a significant impact on the quality of life, nutritional status of the patient and further patient prognosis. The treatment is strictly individual. The first choice should be a conservative approach. Where that fails, a difficult surgical revision is indicated. Today, however, the surgeon can be helped by modern technologies such as fluorescent navigated surgery or treatment of the source with autologous tissue adhesives.

The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.

The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedice papers.

Keywords:

chylous ascites – chyloperitoneum – Lymphatic system – lymphangiography – lymphorrhea – indocyanin green – Vivostat

Sources

1. Weniger M, D’Haese JG, Angele MK et al. Treatment options for chylous ascites after major abdominal surgery: a systematic review. Am J Surg 2016; 211 (1): 206–213. doi: 10.1016/j.amjsurg.2015.04.012.

2. Bhardwaj R, Vaziri H, Gautam A et al. Chylous ascites: a review of pathogenesis, diagnosis and treatment. J Clin Transl Hepatol 2018; 6 (1): 105–113. doi: 10.14218/JCTH.2017.00035.

3. van der Gaag NA, Verhaar AC, Haverkort EB et al. Chylous ascites after pankreaticoduodenectomy: introduction of a grading system. J Am Coll Surg 2008; 207 (5): 751–757. doi: 10.1016/j.jamcollsurg.2008.07. 007.

4. Kim SW, Kim J H. Low-dose radiation therapy for massive chylous leakage after subtotal gastrectomy. Radiat Oncol J 2017; 35 (4): 380–384. doi: 10.3857/roj.2017.00178.

5. Talluri SK, Nuthakki H, Tadakamalla A et al. Chylous ascites. N Am J Med Sci 2011; 3 (9): 438–440. doi: 10.4297/najms.2011.3438.

6. Matějka VM, Fiala O, Tupý R et al. Chylózní ascites jako závažná komplikace neuroendokrinního tumoru ilea – kazuistika. Klin Onkol 2013; 26 (5): 358–361. doi: 10.14735/amko2013358.

7. Frey MK, Ward NM, Caputo TA et al. Lymphatic ascites following pelvic and paraaortic lymphadenectomy procedures for gynecologic malignancies. Gynecol Oncol 2012; 125 (1): 48–53. doi: 10.1016/j.ygyno.2011.11.012.

8. Jelenek G, Náležinská M. Chyloperitoneum – zkušenosti z našeho pracoviště. Onkologie 2015; 9 (1): 43–45.

9. Solmaz U, Turan V, Mat E et al. Chylous ascites following retroperitoneal lymphadenectomy in gynecologic malignancies: incidence, risk factors and management. Int J Surgery 2015; 16: 88–93. doi: 10.1016/j.ijsu.2015. 02.020.

10. Thaler MA, Bietenbeck A, Schulz C et al. Establishment of triglyceride cut-off values to detect chylous ascites and pleural effusions. Clin Biochem 2017; 50 (3): 134–138. doi: 10.1016/j.clinbiochem.2016.10.008.

11. Staats BA, Ellefson RD, Budahn LL et al. The lipoprotein profile of chylous and nonchylous pleural effusions. Mayo Clin Proc 1980; 55 (11): 700–704.

12. Han D, Wu X, Li J et al. Postoperative chylous ascites in patients with gynecologic malignancies. Int J Gynecol Cancer 2012; 22 (2): 186–190. doi: 10.1097/IGC.0b013e31 8233f24b.

13. Galanopoulos G, Konstantopoulos T, Theodorou S et al. Chylous ascites following open abdominal aortic aneurysm repair: an unusual complication. Methodist Debakey Cardiovasc J 2016; 12 (2): 119–121. doi: 10.14797/mdcj-12-2-119.

14. Lee E W, Shin JH, Ko HK et al. Lymphangiography to treat postoperative lymphatic leakage: a technical review. Korean J Radiol 2014; 15 (6): 724–732. doi: 10.3348/kjr.2014.15.6.724.

15. Zhao Y, Hu W, Hou X et al. Chylous ascites after laparoscopic lymph node dissection in gynecologic malignancies. J Minim Invasive Gynecol 2014; 21 (1): 90–96. doi: 10.1016/j.jmig.2013.07.005.

16. Matsutani T, Hirakata A, Nomura T et al. Transabdominal approach for chylorrhea after esophagectomy by using fluorescence navigation with indocyanine green. Case Rep Surg 2014; 2014: 464017. doi: 10.1155/2014/464017.

17. Kuboki S, Shimiyu H, Yoshidome H et al. Chylous ascites after hepatopancreatobiliary surgery. Br J Surg 2013; 100 (4): 522–527. doi: 10.1002/bjs.9013.

18. Shibuya Y, Asano K, Hayasaka A et al. A novel therapeutic strategy for chylous ascites after gynecological cancer surgery: a continuous low-pressure drainage system. Arch Gynecol Obstet 2013; 287 (5): 1005–1008. doi: 10.1007/s00404-012-2666-y.

19. Brown S, Abana CO, Hammad H et al. Low-dose radiotherapy is an effective treatment for refractory post-operative chylous ascites: a case report. Radiat Oncol J 2019; 9 (3): 153–157. doi: 10.1016/j.prro.2018.12.001.

20. Alejandre-Lafont E, Krompiec Ch, Rau WS et al. Effectiveness of therapeutic lymphography on lymphatic leakage. Acta Radiol 2011; 52 (3): 305–311. doi: 10.1258/ar.2010.090356.

21. Kamiya K, Unno N, Konno H. Intraoperative indocyanine green fluorescence lymphography, a novel imaging technique to detect a chyle fistula after an esophagectomy: report of a case. Surg Today 2009; 39 (5): 421–424. doi 10.1007/s00595-008-3852-1.

22. Wada T, Kawada K, Takahashi R et al. ICG fluorescence imaging for quantitative evaluation of colonic perfusion in laparoskopic colorectal surgery. Surg Endosc 2017; 31 (10): 4184–4193. doi: 10.1007/s00464-017-5475-3.

23. Ito M, Hasegawa H, Tsukada Y. Indocyanine green fluorescence angiography during laparoscopic rectal surgery. Ann Laprosc Endosc Surg 2017; 2 (2): 7. doi: 10.21037/ales.2016.12.09.

24. Kawada K, Hasegawa S, Wada T et al. Evaluation of intestinal perfusin by ICG fluorescence imaging in laparoscopic colorectal surgery with DST anastomosis. Surg Endosc 2017; 31 (3): 1061–1069. doi: 10.1007/s00464-016-5064-x.

25. Shirotsuki R, Uchida H, Tanaka Y et al. Novel thoracoscopic navigation surgery for neonatal chylothorax using indocyanine-green fluorescent lymphography. J Pediatr Surg 2018; 53 (6): 1246–1249. doi: 10.1016/j.jpedsurg.2018.01.019.

26. Chakedis J, Shirley LA, Terando AM et al. Identification of the thoracic duct using indocyanine green during cervical lymphadenectomy. Ann Surg Oncol 2018; 25 (12): 3711–3717. doi: 10.1245/s10434-018-6690-4.

27. Chiu CH, Chao YK, Liu YH et al. Clinical use of near-infrared fluorescence imaging with indocyanine green in thoracic surgery: a literature review. J Thorac Dis 2016; 8 (Suppl 9): S744–S748. doi: 10.21037/jtd.2016. 09.70.

28. Kitai T, Inomoto T, Miwa M et al. Fluorescence navigation with indocyanine green for detecting sentinel lymph nodes in breast cancer. Breast Cancer 2005; 12 (3): 211–215. doi: 10.2325/jbcs.12.211.

29. Moračík P, Hlavsa J, Kala Z et al. Platelet rich fibrin sealant Vivostat in pancreatic surgery. Pancreatology 2018; 18 (4): S62. doi: 10.1016/j.pan.2018.05.165.

30. Lassen MR, Solgaard S, Kjersgaard AG et al. A pilot study of the effects of vivostat patient-derived fibrin sealant in reducing blood loss in primary hip arthroplasty. Clin Appl Thromb Hemost 2006; 12 (3): 352–357. doi: 10.1177/1076029606291406.

31. Belcher E, Dusmet M, Jordan S et al. A prospective, randomized trial comparing BioGlue and Vivostat for the control of alveolar air leak. J Thorac Cardiovasc Surg 2010; 140 (1): 32–38. doi: 10.1016/j.jtcvs.2009.11.064.