A 40-year-old man with known retroperitoneal lymphocele presented with right upper quadrant pain and jaundice. He did not describe abuse of tobacco or alcohol, pancreatitis, or a history of trauma or abdominal surgery. He had a tender palpable mass in the right upper quadrant and laboratory results significant for obstructive cholestasis. CT showed a lymphocele measuring 9.4 × 8.6 cm (previously 4.4 × 4 cm), with biliary ductal dilatation (A). He underwent EUS cystduodenostomy (cyst fluid consistent with lymphocele) by the use of two 10F × 1-cm double-pigtail stents (B); the result of cytologic analysis was negative for malignancy. ERCP showed a 25-mm stenosis of the distal common bile duct, with upstream dilatation to 16 mm, treated with stent placement (10F × 7 cm, 7F × 7 cm) (C), which resolved his jaundice. All stents were removed 2 months later, and a cholangiogram showed stricture resolution, with the fistula draining lymphatic fluid (D). Follow-up magnetic resonance imaging 4 months later showed significant sustained improvement of the lymphocele (D).
Lymphoceles usually result from trauma, surgery, or malignancy. Spontaneous lymphoceles are rare. Although they are mostly asymptomatic, symptoms can include abdominal discomfort and constipation. Treatment involves surgical or percutaneous drainage, with endoscopic drainage (transgastric) reported once previously. We believe this is the first reported case of obstructive jaundice from a lymphocele and treatment by transduodenal drainage. The permanent duodenal fistula enabled continuous enteric drainage, preventing symptom recurrence.
Disclosure
All authors disclosed no financial relationships.
Commentary Lymphoceles can arise in the setting of trauma and damage to the native lymphatic ducts. This condition often results from surgical interventions, malignancy, or trauma that disrupts the normal route of lymphatic drainage. In this patient, a large lymphocele developed that extrinsically compressed the bile duct, resulting in obstructive jaundice. This was treated as if the lesion were a pseudocyst and was drained to the duodenum endoscopically, resulting in the resolution of the patient's symptoms.
Although in this case the authors observed a good outcome, drainage of a lymphocele in this manner can potentially result in a chronic lymphatic fistula to the luminal GI tract, which can have adverse consequences, affect fluid and electrolyte balance, and even potentially compromise renal function from fluid losses. The fluid in a lymphocele, as was true in this case, is often milky white, giving a clue to its origin. These are indeed rare lesions—in approximately 20 years of performing EUS I have encountered GI lymphoceles fewer than 1 dozen times.
Douglas G. Adler, MD, FASGE, GIE Senior Associate Editor, University of Utah School of Medicine, Salt Lake City, Utah
Mohamed O. Othman, MD, Associate Editor for Focal Points
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Publication history
Published online: December 19, 2019
Mohamed O. Othman, MD, Associate Editor for Focal PointsIdentification
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© 2019 by the American Society for Gastrointestinal Endoscopy
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