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Lymphoceles and lymphatic fistulae are rare complications of abdominal surgery. External drainage of chyle via the rectum or vagina is unusual and difficult to manage.
After panproctocolectomy for ulcerative colitis a woman of 44 developed a profuse watery vaginal discharge. There were no associated urinary tract or bowel symptoms and swabs from the discharge yielded no evidence of infection. CT revealed a substantial amount of intra-abdominal fluid, which was then drained by abdominoparacentesis, the drain being left in situ. On removal of the drain the discharge persisted. Again no microorganisms could be cultured from it. The watery nature of the discharge and a slight right-sided hydronephrosis noted on a repeat CT scan led to a full urological investigation for a presumptive ureteric or vesicovaginal fistula but none was found. At this point the clinicians speculated that the intra-abdominal fluid collection might be a lymphocyst draining into the vagina. A lymphangiogram was reported as normal but the adequacy of the study was questioned. A second lymphangiogram, deemed satisfactory, was reported as showing no evidence of a lymphatic leak. An exploratory laparotomy revealed no cause for the discharge and a hysterectomy and bilateral salpingo-oophorectomy were undertaken. The discharge persisted and the patient was then referred to St Mark's Hospital, a colorectal tertiary centre. Here, when examined under anaesthesia, she was found to have two holes in the posterior vaginal wall. One of these was cannulated and an intraoperative sinogram was performed under fluoroscopic control. Contrast filled a cavity of about 5×5 cm. Occlusion of the inlet with a pledget provided enough pressure to show filling of an obstructed lymphatic vessel on the right side of the sacrum (Figure 1). The cannulated sinus was extended to facilitate drainage of chyle. The patient declined further interventions.
Chyloperitoneum is a rare complication of abdominal surgery that should be considered in cases of persistent abdominal distension. Sampling should yield sterile, lipaemic fluid. We have found no previous report of a lymphatic fistula draining externally via the rectum or vagina. To determine the site of the leak the mainstay of imaging is lymphangiography,1 though its lack of total sensitivity is illustrated by the present case. Lymphangiography can be done as an intraoperative procedure during attempted surgical repair, and localization may be further improved by injection of patent blue violet.2 CT in conjunction with lymphangiography can help to establish or exclude the presence of associated retroperitoneal masses or lymph node enlargement. It may also be of assistance in improving localization of abnormal retroperitoneal and pelvic lymphatic vessels. Lymphatic leaks have also been localized with the use of oral iodine-marked fatty acids (123I-pentadecanoic acid).3
The management options for lymphatic collections and fistulae include a diet high in medium-chain triglycerides, a period of total parenteral nutrition, insertion of a peritoneovenous shunt, catheter drainage, sclerotherapy with tetracycline and surgical closure.4–7 If the present patient changes her mind about treatment the best option might be surgery to clear tissue away from the vaginal vault.