Video article

Persistent postoperative ascites successfully

Int J Gynecol Cancer: first published as 10.1136/ijgc-2020-001198 on 21 June 2020. Downloaded from http://ijgc.bmj.com/ on April 14, 2024 by guest. Protected by copyright.
identified and treated with laparoscopic
indocyanine green fluorescence
Rodrigo Fernandes ‍ ‍,1 Cristina Anton ‍ ‍,1 Andre Lopes ‍ ‍,1 Alexandre Silva e Silva,1
Eric Leblanc,2 Ulysses Ribeiro Jr,3 Jesus Paula Carvalho ‍ ‍1

1
Obstetricia e Ginecologia, Lymphatic ascites after a lymphadenectomy due to
Universidade de Sao Paulo disruption of lymphatic vessels is a complication
Instituto do Cancer do Estado
de Sao Paulo, Sao Paulo, Brazil
reported to happen in 2.7% of those procedures.1–3
2
Gynecology Oncology, Oscar There are several types of lymphatic leakage
Lambret Cancer Centre, Lille, reported in the literature such as lymphorrhea,
Hauts-­de-­France, France
3
lymphocele, lymphatic ascites, chylous ascites, and
Gastroenterologia, lymphatic fistula. Medical treatment is the primary
Universidade de Sao Paulo
Instituto do Cancer do Estado
treatment of choice and has been reported to cure
de Sao Paulo, Sao Paulo, São ascites in 66% to 77% of cases.1 Surgical treatment
Paulo, Brazil to identify the leakage site should not be considered
Video 1.
as the first choice and is reserved if medical treat-
Correspondence to ment fails to solve it.1 4 Indocyanine green (ICG) and
Rodrigo Fernandes, Obstetricia fluorescence imaging (FI) have been vastly used for triglycerides, and several percutaneous drainages
e Ginecologia, Universidade de different purposes including sentinel lymph node were unsuccessful. Then we decided to perform lapa-
Sao Paulo Instituto do Cancer
do Estado de Sao Paulo, Sao
identification for different types of cancer, retina roscopy, ICG, and FI to fix the leakage.
Paulo, Brazil; ​ropfernandes@​ evaluation, and organ perfusion before resection. In During the procedure 1.2 liters of lymphatic
gmail.​com addition, ICG and FI have potential to solve contem- ascites were drained. An injection of 1 mL of ICG in
porary problems in gynecologic oncology and may three sites of the proximal part of both thighs was
be used to evaluate perfusion of colorectal anasto- performed and after 10 min the use of near infrared
Accepted 30 April 2020
mosis or uterine perfusion after radical trachelec- fluorescence successfully identified the active
tomy.5 6 In this video we present a case where ICG leakage site. Several metal clips were used to stop
and FI were used to help identify the precise site the leakage.
of lymphatic leakage and successfully solve it. After surgery the patient was discharged with no
Different from previous authors who published ICG further complications. Long-­term follow-­up demon-
interdigital foot injection, we demonstrate an alter- strated no more ascites.
native application at the proximal part of the thigh.7 The use of laparoscopy and ICG subcutaneous
A 59-­year-­old woman diagnosed with high-­grade injection appears as a promising technique to iden-
serous ovarian carcinoma FIGO stage IIIC, under- tify active lymphatic leakage and treat it surgically.
went upfront debulking surgery with total hyster- The injection of ICG to the thigh appears to be an
ectomy, bilateral adnexectomy, omentectomy, and alternative to interdigital foot injection.
partial lymphadenectomy in another hospital.
The patient was referred to our institution Correction notice Since the online publication of this article, the
twitter handle for Andre Lopes was updated to @andrelopesMD
and underwent six cycles of chemotherapy with
carboplatin-­paclitaxel, however she persisted with Twitter Andre Lopes @andrelopesMD
© IGCS and ESGO 2020. No enlarged pelvic and para-­aortic lymph nodes, suspi- Contributors RPF (corresponding author): Surgeon, development
commercial re-­use. See rights of paper, review of the literature. CA: Surgeon, development of
cious for secondary involvement without any other
and permissions. Published by paper, review of the literature. AL: Development of paper. UR:
BMJ. sites of metastasis. We decided to perform system- Review of paper. EL: Development and review of paper. JPC:
atic pelvic and para-­aortic lymphadenectomy. A few Development and review of paper.
To cite: Fernandes R, Anton C,
days after the surgery the patient developed ascites Funding The authors have not declared a specific grant for this
Lopes A, et al. Int J Gynecol
Cancer Published Online First: confirmed by the clinical aspect and biochemical research from any funding agency in the public, commercial, or
evaluation of the fluid. not-­for-­profit sectors.
[please include Day Month
Year]. doi:10.1136/ijgc-2020- Conservative treatment consisting of paren- Competing interests None declared.
001198 teral nutrition, a low-­ fat diet with medium-­ chain Patient consent for publication Not required.

Fernandes R, et al. Int J Gynecol Cancer 2020;0:1–2. doi:10.1136/ijgc-2020-001198 1

Provenance and peer review Not commissioned; externally peer reviewed. 3 Cartron G, Leblanc E, Ferron G, et al. Complications des

Int J Gynecol Cancer: first published as 10.1136/ijgc-2020-001198 on 21 June 2020. Downloaded from http://ijgc.bmj.com/ on April 14, 2024 by guest. Protected by copyright.
lymphadénectomies cœlioscopiques en oncologie gynécologique :
Data availability statement Data are available in a public, open access repository 1102 interventions chez 915 patientes. Gynécologie Obstétrique &
Fertilité 2005;33:304–14.
ORCID iDs 4 Micha JP, Mendivil AA, Cupp JS, et al. Recurrent lymphatic ascites
Rodrigo Fernandes http://​orcid.​org/​0000-​0002-​5264-​2166 in a patient cured of cervical carcinoma. Gynecol Oncol Case Rep
Cristina Anton http://​orcid.​org/​0000-​0002-​6259-​2449 2012;2:105–6.
Andre Lopes http://o​ rcid.​org/​0000-​0002-4​ 986-​8738 5 Escobar PF, Ramirez PT, Garcia Ocasio RE, et al. Utility of
Jesus Paula Carvalho http://​orcid.​org/0​ 000-​0003-​4495-​057X indocyanine green (ICG) intra-­operative angiography to determine
uterine vascular perfusion at the time of radical trachelectomy.
Gynecol Oncol 2016;143:357–61.
6 Alekseev M, Rybakov E, Shelygin Y, et al. A study investigating the
perfusion of colorectal anastomoses using fluorescence angiography:
References results of the FLAG randomized trial. Colorectal Dis 2020.
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2 Fernandes R, et al. Int J Gynecol Cancer 2020;0:1–2. doi:10.1136/ijgc-2020-001198