Advances of the interventional treatment for chylous ascites_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

HUANG Qiaosheng ,  FANG Zhihong

Interventional Radiology Department, Xiangtan Central Hospital, Xiangtan, Hunan 411100, P. R. China;

Corresponding author：

FANG Zhihong, Email: fzhyangyang@163.com

Keywords：

chylous ascites; lymphatic intervention; lymphangiography; intranodal lymphangiography; lymphatic embolization

DOI：

10.7507/1007-9424.202411064

Video：

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Objective To understand the application progress of interventional therapy for chylous ascites (CA). Methods The domestic and foreign literature related to the diagnosis, imaging examination methods, and interventional treatment of CA in recent were retrieved and summarized. Results The sources of CA are diverse, the aetiology is different, and the treatment modalities will vary greatly, with the diagnosis of the source of lymphatic leakage being the basis for the effectiveness of interventional therapy. Through interventional treatment, such as intranodal lymphography, hepatic lymphogram, balloon occlusion retrograde abdominal lymphangiography, lymphatic leakage that is difficult to identify in traditional imaging examinations (CT, MRI, etc.) can be located and embolised to improve the diagnosis and treatment of CA. As an emerging means for the treatment of CA, interventional therapy has the advantages of less trauma, quick effect, and fewer complications. Conclusions With the continuous improvement of the interventional treatment approach, angiography, and embolization materials, and the continuous accumulation of clinical experience, the interventional of CA will have more significant therapeutic effects and a broader application prospect.

1.	梁秀珍, 刘晓红, 陆星华, 等. 乳糜腹水22例的病因分析. 中华内科杂志, 1999, 38(8): 3.
2.	王秀茹. 乳糜性腹水247例国内文献分析. 临床荟萃, 2009, 24(6): 513-515.
3.	Besselink MG, van Rijssen LB, Bassi C, et al. Definition and classification of chyle leak after pancreatic operation: a consensus statement by the international study group on pancreatic surgery. Surgery, 2017, 161(2): 365-372.
4.	李再波. 乳糜性腹水的临床分析. 医药论坛杂志, 2011, 32(8): 20-22.
5.	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.
6.	Youssef EW, Aly A, Brahmbhatt A, et al. Lymphatic interventions in the cancer patient. Curr Oncol Rep, 2022, 24(10): 1351-1361.
7.	Braun CM, Ryu JH. Chylothorax and pseudochylothorax. Clin Chest Med. 2021;42(4): 667-675.
8.	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.
9.	李越, 丁惠国. 乳糜性腹水诊治现状. 实用肝脏病杂志, 2018, 21(5): 665-668.
10.	Hur S, Kim J, Ratnam L, et al. Lymphatic intervention, the frontline of modern lymphatic medicine: part I. History, anatomy, physiology, and diagnostic imaging of the lymphatic system. Korean J Radiol, 2023, 24(2): 95-108.
11.	Clément O, Luciani A. Imaging the lymphatic system: possibilities and clinical applications. Eur Radiol, 2004, 14(8): 1498-1507.
12.	Jaleel J, Nasurudeen S, Babu AS, et al. Utility of ^99mTc-sulfur colloid lymphoscintigraphy and SPECT/CT in chylothorax and chylous ascites. Nucl Med Mol Imaging, 2023, 57(6): 265-274.
13.	刘定益, 夏维木, 王健, 等. 足背淋巴管造影在乳糜尿患者诊断和治疗中的作用. 中华泌尿外科杂志, 2018, 39(6): 446-450.
14.	白旭, 包晗, 黄媛丹, 等. 经腹股沟淋巴结穿刺淋巴管造影诊断和治疗乳糜漏6例. 介入放射学杂志, 2023, 32(2): 158-161.
15.	Wan J, Zhang W, Yu C, et al. Application of ultrasound-guided intranodal lymphangiography in the diagnosis and treatment of chylous ascites after abdominal surgery. Pol J Radiol, 2024, 89: e502-e507. doi: 10.5114/pjr/193577.
16.	Matsumoto S, Mori H, Tada I. Successful demonstration of post-operative lymphatic fistula by percutaneous transhepatic lymphography. Clin Radiol, 2000, 55(6): 485-486.
17.	Brisson BA, Holmberg DL, House M. Comparison of mesenteric lymphadenography performed via surgical and laparoscopic approaches in dogs. Am J Vet Res, 2006, 67(1): 168-173.
18.	Lee H, Kim SJ, Hur S, et al. The feasibility of mesenteric intranodal lymphangiography: its clinical application for refractory postoperative chylous ascites. J Vasc Interv Radiol, 2018, 29(9): 1290-1292.
19.	Woo SJ, Hur S, Kim HS, et al. Hybrid lymphovenous anastomosis surgery guided by intraoperative mesenteric intranodal lymphangiography for refractory nontraumatic chylous ascites: a case report. Arch Plast Surg, 2024, 51(1): 130-134.
20.	Kinmonth JB, Cox SJ. Protein-losing enteropathy in primary lymphoedema: mesenteric lymphography and gut resection. Br J Surg, 1974, 61(8): 589-593.
21.	Tan X, Luo G, Liao G, et al. Postoperative chylous ascites in gynecological malignancies: two case reports and a literature review. Obstet Gynecol Int, 2024, 2024: 1810634. doi: 10.1155/2024/1810634.
22.	DiBattista JV, Odenwald MA, Te H. Successful treatment of refractory chylous ascites with octreotide in a patient with decompensated cirrhosis. ACG Case Rep J, 2024, 11(4): e01322. doi: 10.14309/crj.0000000000001322.
23.	Ng ZQ, Han M, Beh HN, et al. Chylous ascites in colorectal surgery: a systematic review. World J Gastrointest Surg, 2021, 13(6): 585-596.
24.	Matsumura M, Mise Y, Takemura N, et al. An elemental diet reduces chylous ascites of patients undergoing pancreatoduodenectomy in the setting of early enteral feeding. Pancreas, 2024, 53(4): e343-e349. doi: 10.1097/MPA.0000000000002309.
25.	Hasegawa T, Tsuboi M, Fukushima K, et al. Refractory hepatic lymphorrhea: percutaneous transhepatic lymphangiography and embolization with n-Butyl-2-Cyanoacrylate glue. Cardiovasc Intervent Radiol, 2021, 44(7): 1127-1130.
26.	Hur S, Jun H, Jeong YS. Novel interventional radiological management for lymphatic leakages after gynecologic surgery: lymphangiography and embolization. Gland Surg, 2021, 10(3): 1260-1267.
27.	Lee S, Hur S, Jeong YS. Balloon-occluded retrograde transcatheter magnetic resonance lymphangiography to detect leakage in postoperative chylous ascites. J Vasc Interv Radiol, 2021, 32(4): 617-619.
28.	Guez D, Nadolski GJ, Pukenas BA, et al. Transhepatic lymphatic embolization of intractable hepatic lymphorrhea. J Vasc Interv Radiol, 2014, 25(1): 149-150.
29.	Hur S. Novel interventional radiology for the treatment of various lymphatic leakages: lymphatic intervention and embolization. Vasc Specialist Int, 2023, 39: 42. doi: 10.5758/vsi.230082.
30.	Sumitani R, Higashi K, Oura M, et al. Effective intractable chylous ascites treatment by lymphangiography with lipiodol in a patient with follicular lymphoma. Intern Med, 2025, 64(8): 1223-1228.
31.	Aly AK, Santos E, Fung J, et al. Intranodal lymphangiography and embolization for management of iatrogenic chylous ascites after oncological surgery. J Vasc Interv Radiol, 2024, 35(6): 883-889.
32.	Hur S, Shin JH, Lee IJ, et al. Early experience in the management of postoperative lymphatic leakage using lipiodol lymphangiography and adjunctive glue embolization. J Vasc Interv Radiol, 2016, 27(8): 1177-1186.
33.	Nadolski GJ, Chauhan NR, Itkin M. Lymphangiography and lymphatic embolization for the treatment of refractory chylous ascites. Cardiovasc Intervent Radiol, 2018, 41(3): 415-423.
34.	Majdalany BS, El-Haddad G. Contemporary lymphatic interventions for post-operative lymphatic leaks. Transl Androl Urol, 2020, 9(Suppl 1): S104-S113. doi: 10.21037/tau.2019.08.15.
35.	Kim PH, Tsauo J, Shin JH. Lymphangiography with or without embolization for the treatment of postoperative chylous ascites. Ann Vasc Surg, 2020, 68: 351-360.
36.	Hur S, Kim J, Ratnam L, et al. Lymphatic intervention, the frontline of modern lymphatic medicine: part II. classification and treatment of the lymphatic disorders. Korean J Radiol, 2023, 24(2): 109-132.
37.	Verhaeghe L, Holsbeeck AV, Bonne L, et al. Therapeutic lymphangiography with ethiodized oil for the management of lymphoceles and chylous ascites. Diagn Interv Imaging, 2023, 104(10): 500-505.
38.	Gukasyan J, Phan AT, Hu J, et al. Left-sided transudative chylothorax with concomitant chylous ascites in the setting of liver cirrhosis. Cureus, 2023, 15(1): e33866. doi: 10.7759/cureus.33866.
39.	Yazici SE, Turan E, Atasever A. A rare type of ascites in liver cirrhosis: chylous ascites. Asian J Surg, 2025, 48(1): 465-466.
40.	Tsauo J, Shin JH, Han K, et al. Transjugular intrahepatic portosystemic shunt for the treatment of chylothorax and chylous ascites in cirrhosis: a case report and systematic review of the literature. J Vasc Interv Radiol, 2016, 27(1): 112-116.
41.	Huang Y, Gloviczki P, Duncan AA, et al. Management of refractory chylous ascites with peritoneovenous shunts. J Vasc Surg Venous Lymphat Disord, 2017, 5(4): 538-546.
42.	刘中, 沈文彬, 孙宇光, 等. 胃癌根治术后肝源性淋巴漏6例诊治分析. 中华普通外科杂志, 2024, 39(9): 715-716.
43.	Yarmohammadi H, Schilsky J, Durack JC, et al. Treatment of chylous ascites with peritoneovenous shunt (Denver Shunt) following retroperitoneal lymph node dissection in patients with urological malignancies: update of efficacy and predictors of complications. J Urol, 2020, 204(4): 818-823.
44.	常鲲, 夏松, 孙宇光, 等. 腹腔-静脉分流术治疗难治性乳糜腹水的疗效分析. 中华普通外科杂志, 2022(9): 660-664.
45.	Oblizajek NR, Kamath PS. Resolution of loculated chylous ascites using intraperitoneal fibrinolytic therapy. Hepatology, 2021, 74(4): 2293-2295.
46.	Tindale A, Jackson J, Kohoutova D, et al. Complete resolution of acute pancreatitis-induced chylous ascites following transhepatic portal vein stenting. BMJ Case Rep, 2020, 13(12): e235986. doi: 10.1136/bcr-2020-235986.

1. 梁秀珍, 刘晓红, 陆星华, 等. 乳糜腹水22例的病因分析. 中华内科杂志, 1999, 38(8): 3.
2. 王秀茹. 乳糜性腹水247例国内文献分析. 临床荟萃, 2009, 24(6): 513-515.
3. Besselink MG, van Rijssen LB, Bassi C, et al. Definition and classification of chyle leak after pancreatic operation: a consensus statement by the international study group on pancreatic surgery. Surgery, 2017, 161(2): 365-372.
4. 李再波. 乳糜性腹水的临床分析. 医药论坛杂志, 2011, 32(8): 20-22.
5. 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.
6. Youssef EW, Aly A, Brahmbhatt A, et al. Lymphatic interventions in the cancer patient. Curr Oncol Rep, 2022, 24(10): 1351-1361.
7. Braun CM, Ryu JH. Chylothorax and pseudochylothorax. Clin Chest Med. 2021;42(4): 667-675.
8. 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.
9. 李越, 丁惠国. 乳糜性腹水诊治现状. 实用肝脏病杂志, 2018, 21(5): 665-668.
10. Hur S, Kim J, Ratnam L, et al. Lymphatic intervention, the frontline of modern lymphatic medicine: part I. History, anatomy, physiology, and diagnostic imaging of the lymphatic system. Korean J Radiol, 2023, 24(2): 95-108.
11. Clément O, Luciani A. Imaging the lymphatic system: possibilities and clinical applications. Eur Radiol, 2004, 14(8): 1498-1507.
12. Jaleel J, Nasurudeen S, Babu AS, et al. Utility of ^99mTc-sulfur colloid lymphoscintigraphy and SPECT/CT in chylothorax and chylous ascites. Nucl Med Mol Imaging, 2023, 57(6): 265-274.
13. 刘定益, 夏维木, 王健, 等. 足背淋巴管造影在乳糜尿患者诊断和治疗中的作用. 中华泌尿外科杂志, 2018, 39(6): 446-450.
14. 白旭, 包晗, 黄媛丹, 等. 经腹股沟淋巴结穿刺淋巴管造影诊断和治疗乳糜漏6例. 介入放射学杂志, 2023, 32(2): 158-161.
15. Wan J, Zhang W, Yu C, et al. Application of ultrasound-guided intranodal lymphangiography in the diagnosis and treatment of chylous ascites after abdominal surgery. Pol J Radiol, 2024, 89: e502-e507. doi: 10.5114/pjr/193577.
16. Matsumoto S, Mori H, Tada I. Successful demonstration of post-operative lymphatic fistula by percutaneous transhepatic lymphography. Clin Radiol, 2000, 55(6): 485-486.
17. Brisson BA, Holmberg DL, House M. Comparison of mesenteric lymphadenography performed via surgical and laparoscopic approaches in dogs. Am J Vet Res, 2006, 67(1): 168-173.
18. Lee H, Kim SJ, Hur S, et al. The feasibility of mesenteric intranodal lymphangiography: its clinical application for refractory postoperative chylous ascites. J Vasc Interv Radiol, 2018, 29(9): 1290-1292.
19. Woo SJ, Hur S, Kim HS, et al. Hybrid lymphovenous anastomosis surgery guided by intraoperative mesenteric intranodal lymphangiography for refractory nontraumatic chylous ascites: a case report. Arch Plast Surg, 2024, 51(1): 130-134.
20. Kinmonth JB, Cox SJ. Protein-losing enteropathy in primary lymphoedema: mesenteric lymphography and gut resection. Br J Surg, 1974, 61(8): 589-593.
21. Tan X, Luo G, Liao G, et al. Postoperative chylous ascites in gynecological malignancies: two case reports and a literature review. Obstet Gynecol Int, 2024, 2024: 1810634. doi: 10.1155/2024/1810634.
22. DiBattista JV, Odenwald MA, Te H. Successful treatment of refractory chylous ascites with octreotide in a patient with decompensated cirrhosis. ACG Case Rep J, 2024, 11(4): e01322. doi: 10.14309/crj.0000000000001322.
23. Ng ZQ, Han M, Beh HN, et al. Chylous ascites in colorectal surgery: a systematic review. World J Gastrointest Surg, 2021, 13(6): 585-596.
24. Matsumura M, Mise Y, Takemura N, et al. An elemental diet reduces chylous ascites of patients undergoing pancreatoduodenectomy in the setting of early enteral feeding. Pancreas, 2024, 53(4): e343-e349. doi: 10.1097/MPA.0000000000002309.
25. Hasegawa T, Tsuboi M, Fukushima K, et al. Refractory hepatic lymphorrhea: percutaneous transhepatic lymphangiography and embolization with n-Butyl-2-Cyanoacrylate glue. Cardiovasc Intervent Radiol, 2021, 44(7): 1127-1130.
26. Hur S, Jun H, Jeong YS. Novel interventional radiological management for lymphatic leakages after gynecologic surgery: lymphangiography and embolization. Gland Surg, 2021, 10(3): 1260-1267.
27. Lee S, Hur S, Jeong YS. Balloon-occluded retrograde transcatheter magnetic resonance lymphangiography to detect leakage in postoperative chylous ascites. J Vasc Interv Radiol, 2021, 32(4): 617-619.
28. Guez D, Nadolski GJ, Pukenas BA, et al. Transhepatic lymphatic embolization of intractable hepatic lymphorrhea. J Vasc Interv Radiol, 2014, 25(1): 149-150.
29. Hur S. Novel interventional radiology for the treatment of various lymphatic leakages: lymphatic intervention and embolization. Vasc Specialist Int, 2023, 39: 42. doi: 10.5758/vsi.230082.
30. Sumitani R, Higashi K, Oura M, et al. Effective intractable chylous ascites treatment by lymphangiography with lipiodol in a patient with follicular lymphoma. Intern Med, 2025, 64(8): 1223-1228.
31. Aly AK, Santos E, Fung J, et al. Intranodal lymphangiography and embolization for management of iatrogenic chylous ascites after oncological surgery. J Vasc Interv Radiol, 2024, 35(6): 883-889.
32. Hur S, Shin JH, Lee IJ, et al. Early experience in the management of postoperative lymphatic leakage using lipiodol lymphangiography and adjunctive glue embolization. J Vasc Interv Radiol, 2016, 27(8): 1177-1186.
33. Nadolski GJ, Chauhan NR, Itkin M. Lymphangiography and lymphatic embolization for the treatment of refractory chylous ascites. Cardiovasc Intervent Radiol, 2018, 41(3): 415-423.
34. Majdalany BS, El-Haddad G. Contemporary lymphatic interventions for post-operative lymphatic leaks. Transl Androl Urol, 2020, 9(Suppl 1): S104-S113. doi: 10.21037/tau.2019.08.15.
35. Kim PH, Tsauo J, Shin JH. Lymphangiography with or without embolization for the treatment of postoperative chylous ascites. Ann Vasc Surg, 2020, 68: 351-360.
36. Hur S, Kim J, Ratnam L, et al. Lymphatic intervention, the frontline of modern lymphatic medicine: part II. classification and treatment of the lymphatic disorders. Korean J Radiol, 2023, 24(2): 109-132.
37. Verhaeghe L, Holsbeeck AV, Bonne L, et al. Therapeutic lymphangiography with ethiodized oil for the management of lymphoceles and chylous ascites. Diagn Interv Imaging, 2023, 104(10): 500-505.
38. Gukasyan J, Phan AT, Hu J, et al. Left-sided transudative chylothorax with concomitant chylous ascites in the setting of liver cirrhosis. Cureus, 2023, 15(1): e33866. doi: 10.7759/cureus.33866.
39. Yazici SE, Turan E, Atasever A. A rare type of ascites in liver cirrhosis: chylous ascites. Asian J Surg, 2025, 48(1): 465-466.
40. Tsauo J, Shin JH, Han K, et al. Transjugular intrahepatic portosystemic shunt for the treatment of chylothorax and chylous ascites in cirrhosis: a case report and systematic review of the literature. J Vasc Interv Radiol, 2016, 27(1): 112-116.
41. Huang Y, Gloviczki P, Duncan AA, et al. Management of refractory chylous ascites with peritoneovenous shunts. J Vasc Surg Venous Lymphat Disord, 2017, 5(4): 538-546.
42. 刘中, 沈文彬, 孙宇光, 等. 胃癌根治术后肝源性淋巴漏6例诊治分析. 中华普通外科杂志, 2024, 39(9): 715-716.
43. Yarmohammadi H, Schilsky J, Durack JC, et al. Treatment of chylous ascites with peritoneovenous shunt (Denver Shunt) following retroperitoneal lymph node dissection in patients with urological malignancies: update of efficacy and predictors of complications. J Urol, 2020, 204(4): 818-823.
44. 常鲲, 夏松, 孙宇光, 等. 腹腔-静脉分流术治疗难治性乳糜腹水的疗效分析. 中华普通外科杂志, 2022(9): 660-664.
45. Oblizajek NR, Kamath PS. Resolution of loculated chylous ascites using intraperitoneal fibrinolytic therapy. Hepatology, 2021, 74(4): 2293-2295.
46. Tindale A, Jackson J, Kohoutova D, et al. Complete resolution of acute pancreatitis-induced chylous ascites following transhepatic portal vein stenting. BMJ Case Rep, 2020, 13(12): e235986. doi: 10.1136/bcr-2020-235986.

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