Woo Soo Jin, Hur Saebeom, Kim Hee Seung, Chang Hak, Kim Ji-Young, Park Soo Jin, Jin Ung Sik
Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea.
Department of Radiology, Seoul National University College of Medicine, Seoul, Republic of Korea.
Arch Plast Surg. 2024 Feb 28;51(1):130-134. doi: 10.1055/s-0043-1776304. eCollection 2024 Jan.
Refractory chylous ascites can cause significant nutritional and immunologic morbidity, but no clear treatment has been established. This article introduces a case of a 22-year-old female patient with an underlying lymphatic anomaly who presented with refractory chylous ascites after laparoscopic adnexectomy for ovarian teratoma which aggravated after thoracic duct embolization. Ascites (>3,000 mL/d) had to be drained via a percutaneous catheter to relieve abdominal distention and consequent dyspnea, leading to significant cachexia and weight loss. Two sessions of hybrid lymphovenous anastomosis (LVA) surgery with intraoperative mesenteric lymphangiography guidance were performed to decompress the lymphatics. The first LVA was done between inferior mesenteric vein and left para-aortic enlarged lymphatics in a side-to-side manner. The daily drainage of chylous ascites significantly decreased to 130 mL/day immediately following surgery but increased 6 days later. An additional LVA was performed between right ovarian vein and enlarged lymphatics in aortocaval area in side-to-side and end-to-side manner. The chylous ascites resolved subsequently without any complications, and the patient was discharged after 2 weeks. The patient regained weight without ascites recurrence after 22 months of follow-up. This case shares a successful experience of treating refractory chylous ascites with lymphatic anomaly through LVA, reversing the patient's life-threatening weight loss. LVA was applied with a multidisciplinary approach using intraoperative mesenteric lipiodol, and results showed the possibility of expanding its use to challenging problems in the intraperitoneal cavity.
难治性乳糜性腹水可导致严重的营养和免疫相关疾病，但尚未确立明确的治疗方法。本文介绍了一例22岁女性患者，其存在潜在的淋巴管异常，在因卵巢畸胎瘤行腹腔镜附件切除术后出现难治性乳糜性腹水，在胸导管栓塞后病情加重。腹水（>3000 mL/d）必须通过经皮导管引流以缓解腹胀及随之而来的呼吸困难，导致显著的恶病质和体重减轻。在术中肠系膜淋巴管造影引导下进行了两期混合淋巴静脉吻合术（LVA）以减轻淋巴管压力。第一期LVA是在肠系膜下静脉与左主动脉旁肿大的淋巴管之间进行侧侧吻合。术后乳糜性腹水的每日引流量立即显著降至130 mL/天，但6天后又增加。第二期LVA是在右卵巢静脉与主动脉腔静脉区域肿大的淋巴管之间以侧侧和端侧吻合的方式进行。随后乳糜性腹水消退，无任何并发症，患者在2周后出院。随访22个月后，患者体重恢复，腹水未复发。该病例分享了通过LVA治疗伴有淋巴管异常的难治性乳糜性腹水的成功经验，扭转了患者危及生命的体重减轻状况。LVA采用术中肠系膜碘油的多学科方法应用，结果表明有可能将其应用扩展到解决腹腔内具有挑战性的问题。
