Intraoperative indocyanine green fluorescent lymphangiography combined with fibrin glue successfully treated refractory chylous ascites after robotic‐assisted para‐aortic lymphadenectomy for rectal cancer

Dear Editor, Paraaortic lymph node (PALN) metastasis is a rare systemic metastasis from colorectal cancer (CRC), ranging in incidence from 1.2% to 2.1% [1, 2]. Currently, there is no uniform consensus on the diagnosis and treatment for colorectal PALN metastasis. Previous studies have demonstrated that PALN dissection is associated with acceptable postoperative complications and better longterm outcomes in selected CRC patients with PALN metastasis [3]. Regarding the surgical approach, laparoscopic PALN dissection showed good technical safety in cervical cancer patients with PALN metastasis [4]. However, laparoscopic PALN dissection has not been promoted in CRC patients due to the low incidence of PALN metastases and concerns about technical and oncological safety [5, 6]. Since 2012, laparoscopic surgery has been routinely performed on patients with PALN metastasis in our institution, with more than 10 patients undergoing roboticassisted PALN dissection. We previously reported that postoperative complications following PALN dissection occurred in 27.3% of patients (42/154), and the second most frequent morbidity was chylous ascites (7.8%, n = 12) [7]. Currently, the standard conservative treatment for chylous ascites consists of a medium chain triglyceridebased diet, total parenteral nutrition and the addition of somatostatin or octreotide [8]. We previously showed that 4% of CRC patients (11/277) developed refractory chylous ascites after conservative treatment [8]. However, the surgical treatment strategy for refractory chylous ascites for CRC remains inconclusive. Herein, we report the successful experience of intraoperative indocyanine green (ICG) fluorescence lymphangiography combined with fibrin glue to treat refractory chylous ascites for a rectal cancer patient who underwent roboticassisted PALN dissection after neoadjuvant chemoradiotherapy. A 64yearold male patient complaining of rectal bleeding was admitted to our department. The colonoscopy revealed rectal cancer located 7 cm from the anal margin. Wholeabdominal magnetic resonance imaging staged the primary tumour as cT4N2M1a, with PALN metastasis located below the left renal vein. The patient was