Sequential imaging approach with lymphoscintigraphy and intraoperative indocyanine green lymphography for refractory...

A 4-month-old female presented with progressive abdominal distention and feeding difficulties. Diagnostic laparoscopy with peritoneal drainage yielded 970 mL of milky ascites. Fluid analysis confirmed chylous ascites (triglyceride level, 3177 mg/dL; lymphocyte predominance, 94.8%) with negative culture and cytology results. Contrast-enhanced abdominal computed tomography revealed massive ascites without intra-abdominal lesions or significant lymphadenopathy. Despite conservative therapy and continuous high-output drainage (approximately 500 mL/day), the leak persisted. Planar lymphoscintigraphy with technetium-99m radiotracer injected subcutaneously into the dorsum of both feet confirmed lymphatic leakage into the ascites and provided regional guidance regarding the suspected source; however, no discrete focal hotspots were identified. Based on these scintigraphic findings, intraoperative near-infrared fluorescence lymphography using indocyanine green was performed the following day, enabling real-time visualization of active leakage and facilitating targeted laparoscopic treatment. Targeted electrocautery ablation markedly reduced leakage on real-time fluorescence imaging, and a fibrin sealant was subsequently applied. The patient ultimately achieved full oral feeding and showed no recurrence of ascites at the 2-year follow-up. This case illustrates a practical sequential imaging approach for refractory pediatric chylous ascites: lymphoscintigraphy for functional confirmation and regional guidance, followed by intraoperative indocyanine green fluorescence for focal confirmation and targeted treatment.