Treatment of Refractory Ascites with Lymphaticovenous Anastomosis Considering Lymphatic Territories

Lymphatic ascites is an infrequent complication observed in patients who have undergone lymphadenectomy as part of their surgical treatment for gynecological cancer. Previous research has suggested that intranodal lymphangiography can effectively manage lymphatic leakage. However, its efficacy diminishes for ascites with substantial fluid accumulation. This case report presents a patient who underwent lymphaticovenous anastomosis (LVA) for ascites that was unresponsive to lymphangiography and sclerotherapy. A 70-year-old woman required weekly ascites punctures after surgical treatment of ovarian cancer. Lymphoscintigraphy revealed lymphatic leakage originating from the right pelvic lymphatic vessel. Intranodal lymphangiography was performed from the inferior lateral inguinal region, followed by embolization with 33% NBCA. Despite these measures, recurrence of ascites and lower limb lymphedema were observed. LVA was conducted at 149 days after the primary operation. Before the LVA, indocyanine green was injected into the lateral and medial ankles, first and fourth toe web spaces, and lower abdomen. The indocyanine green lymphography revealed several linear patterns extending from the dorsum of the foot and the lower abdomen to the inguinal lymph node. Among these, the lymphatic vessels leading to the inferior lateral inguinal lymph node were chosen for the LVA. Eight anastomoses were executed at the right thigh, right lower leg, and right lower abdomen. The patient was discharged at 1 day postoperatively. A computed tomography examination conducted at 20 days post-LVA revealed no accumulation of ascites. To improve the success rate of LVA for ascites, a treatment strategy based on lymphatic territories is required.