Unprecedented diagnostic method assists the East Hospital physicians in detecting and addressing the cause of a rare post-operative complication

Combining insights from international medical research with their own clinical experience, physicians at the Riga East Clinical University Hospital (East Hospital) have implemented a creative solution and applied an unprecedented diagnostic method on a patient with rare post-operative complications. Intraoperative fluorescence lymphography allowed to identify a damaged lymphatic vessel segment measuring just 0.2 millimetres. During the surgery, this defect was successfully sealed. As a result, the surgeons at the East Hospital were able to prevent significant and complex health issues, restoring the patient to their normal daily life. This surgery is unparalleled not only in Latvia but also globally.

The patient is a 42-year-old Latvian citizen who has been living permanently in the United Kingdom for many years. In May 2024, the patient was hospitalized, examined, and treated at one of the largest hospitals in the United Kingdom. He was diagnosed with a rare complication of acute pancreatitis – a haemorrhagic pancreatic pseudocyst.

“Examinations, including abdominal CT and angiography, indicated that the cause of the bleeding was spleen artery damage caused by inflammation. The patient underwent arterial embolization, followed by ultrasound-guided drainage of the haemorrhagic pseudocyst, or bleeding accumulation. A special drainage tube was inserted, and haemorrhagic contents, or lysed haematoma, were removed. Over time, the drain was removed, and the patient was discharged for outpatient treatment,” explains Jānis Pāvulāns, the attending physician and surgeon at the General and Emergency Surgery Clinic of the East Hospital, describing the patient’s previous complex health issues.

However, within a month, the patient’s health problems recurred. They persisted, manifesting as constant abdominal discomfort, with rapid and significant increase of the abdominal volume. Once again, the patient sought medical assistance from physicians in the United Kingdom. The abdominal CT scan revealed a large amount of fluid of unclear origin in the abdominal cavity. In July, the patient underwent ultrasound-guided abdominal drainage, yielding a very large amount of white, milky fluid of approximately 11 litres.

The analysis showed a high fat (triglyceride) content, confirming a diagnosis of chylous ascites, caused by a damaged lymphatic vessel in the abdominal cavity with an unclear location, leading to the leakage of lymphatic fluid into the abdominal cavity.

To locate the lymphatic vessel damage, the patient underwent multiple imaging diagnostic examinations in the United Kingdom – a total of seven CT scans and several MRI scans. However, it was not possible to visualise the specific defect or the exact location of the lymphatic leakage.

The increasing abdominal volume not only caused discomfort, requiring the use of strong pain medication, but also led to dysfunction of abdominal organs. Due to respiratory difficulties at night, the patient experienced breathing problems. By November 2024, the patient had already undergone three abdominal cavity drainage procedures, with each procedure removing between 9 and 11 litres of lymphatic fluid.

Unable to receive the necessary treatment support in the United Kingdom, the patient returned to Latvia and sought medical assistance at the East Hospital. “I consulted the patient remotely and reviewed the imaging diagnostic examinations, and the only way to potentially help him seemed to be the application of an innovative diagnostic method – fluorescence lymphography – which had not been used in Latvia before,” explains surgeon Jānis Pāvulāns. This became a pivotal point in the patient’s treatment as “the idea of fluorescence lymphography allowed our team to figure out how we could attempt to locate the lymphatic vessel damage”.

Fluorescence lymphography involves injecting a contrast agent into the tissues of the abdominal cavity around the location of the potential lymphatic vessel damage. The agent is then absorbed and enters the lymphatic vessels. A specialised video system and fluorescent light spectrum enables, to the extent possible, the visualisation of the lymphatic vessel from which the lymphatic fluid is leaking, allowing for its subsequent surgical closure.

“Upon commencing the surgery, a large amount of white fluid was observed in the abdominal cavity. Before the surgery, we calculated the daily volume of lymphatic leakage and determined that approximately 100 millilitres of fluid was leaking from the damaged site per day. It is impossible to detect lymphatic leakage of this volume from a lymphatic vessel damage without using specialised visualisation systems. During the surgery, fluorescent dye was injected at several locations in the abdominal cavity. Using infrared light, we could see the lymphatic vessels filling and staining. However, the defect site was not visible at first. We proceeded to explore the area near the location of the potential lymphatic vessel damage indicated by the MRI, which was located very close to the abdominal aorta. We injected the dye next to the aorta and performed repeated fluorescence lymphography. A few minutes later, we initially observed the lymphatic vessels staining, and after approximately five more minutes, we were able to identify the exact location of the lymphatic vessel damage and the lymphatic leakage. After conducting repeated examinations of the potentially damaged lymphatic vessel, we were undoubtedly certain that we had located the damage. The only remaining step was to surgically seal it. The defect in the lymphatic vessel was extremely small – around 0.2 millimetres – which is very difficult to identify even with the naked eye. As for the size of lymphatic capillaries, they are even smaller,” explains surgeon Jānis Pāvulāns, sharing insights into the complex nuances of the treatment.

A multidisciplinary medical team, including surgeon Jānis Pāvulāns, Professor Haralds Plaudis, and resident Sabīne Lūkina, performed a combined surgical closure of the defect site. They used both electrocoagulation and a specialised haemostatic sponge with fibrin-forming properties to seal the defect. At the end of the surgery, a drainage system was placed in the area to monitor fluid leakage during the post-operative period and make sure the defect was fully closed.

The patient’s condition improved rapidly, and on the fourth post-operative day, he was discharged for outpatient treatment. The patient’s health was monitored through periodic consultations with the surgeon. Currently, communication with the patient takes place remotely. He has fully recovered, returned to his regular work and social life, and no longer requires pain management therapy.

Reflecting on the case, the entire surgical team feels a great sense of accomplishment. When asked why his colleagues had not pursued further solutions after the failure of conservative treatment, surgeon Jānis Pāvulāns responded that it was most likely due to a lack of confidence that the defect could be located during surgery without access to specialised visualisation systems.

Given that this surgery is unparalleled not only in Latvia but also globally, surgeon Jānis Pāvulāns and his mentor Professor Haralds Plaudis intend to document and publish this clinical case in an international medical journal.

The multidisciplinary team at East Hospital that performed the surgery and were involved in the patient’s care:

Jānis Pāvulāns, surgeon at the General and Emergency Surgery Clinic

Professor Haralds Plaudis, Board Member of the East Hospital and lead specialist in surgery

Sabīne Lūkina, surgical resident

Anaesthesiology Clinic:

Sergejs Grigorjevs, anaesthesiologist-intensivist

Jana Kalniņa, anaesthesiology resident

Dace Šmite, anaesthesia nurse

Radiology Centre:

Aina Kratovska, Head of the Radiology Centre and interventional radiologist       

Veronika Zaiceva, interventional radiologist 

Radiologists: Reinis Laguns and Vitālijs Lobarevs

Radiologists: Lilita Roznere and Antra Bērziņa

Operating unit:

Pēteris Tomiņš, Head of the Operating Unit

Nataļja Vološko, OR nurse

Ambera Velga Timmonsa, orderly

About the East Hospital 

Riga East Clinical University Hospital is the largest and strategically significant multi-profile hospital in the country. The hospital consists of five inpatient facilities – Gaiļezers, Latvian Oncology Centre, Biķernieki, Tuberculosis and Lung Disease Centre, and Latvian Infectious Diseases Centre, along with various specialised centres and clinics. The hospital provides highly specialised inpatient and secondary outpatient healthcare, offering multidisciplinary tertiary-level treatment and care in line with modern technology and medical knowledge. Approximately 80% of all cancer patients in Latvia are treated at the hospital. It serves as a practical training base for both Latvian educational institutions and foreign students, providing further education and knowledge transfer to healthcare specialists within and beyond the country. The hospital engages in scientific research and develops innovative methods for patient treatment. As the third-largest employer in the country, the hospital employs around 5000 staff members.