PMC6156688_01
(A) Abdominal CT scan axial, coronal, and sagittal showing retroperitoneal chyle leak (arrow). (B) Lymphangiography shows the extravasated iodixanol (arrow) at fourth lumbar spine level within retroperitoneum.
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This showed a large left retroperitoneal fluid collection (Fig. 1A) that caused slight left hydronephrosis and retroperitoneal lymph node enlargement in the interaortocaval, precaval, and right common iliac artery territories. Iodixanol 270 mg/mL contrast (Visipaque ; GE Healthcare) was injected and the radiographic image showed perfect opacification of the lymphatic afferent and efferent vessels of the punctured lymph node and contrast leakage at the level of the fourth lumbar spine, within the retroperitoneum (inferior to the cisterna chyli) (Fig. 1B).
(A) Draining sinus in retroperitoneal location before direct Injection of inguinal lymph node with methylene blue. (B) Draining sinus 4 minutes after direct injection of inguinal lymph node with methylene blue (white circle shows the leak point as a blue spot).
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After identification of the chyle collection (Fig. 2A), the interventional radiologist performed intraoperative lymphography through direct inguinal lymph node puncture (as described previously) to corroborate the findings and then proceeded to the injection of 5 mL methylene blue in the cannulated lymph node. Four minutes later, leakage of methylene blue in the retroperitoneum (Fig. 2B) was identified, with localization of the leakage point.