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Yarmohammadi et al describe the Memorial Sloan Kettering experience in treating 20 patients with refractory chylous ascites following retroperitoneal lymph node dissection, largely in patients with germ cell tumors. They report 90% resolution of chylous ascites with the use of Denver shunts in these refractory cases. Certainly, if one does enough of these procedures, one will encounter cases that are refractory to conservative measures. Once chylous ascites is diagnosed following RPLND at our institution, initial conservative measures include a paracentesis and placement on a low-fat diet of less than 10 gm per day. If the fluid significantly reaccumulates, we then place a peritoneal drain rather than repeated paracenteses and institute TPN and restrict diet to only sips of clear liquid for comfort. We believe prompt escalation of care minimizes the duration of ascites. We have found this algorithm resolves the vast majority of cases. However, patience is a virtue, especially in the setting of high volume ascites that can take 6 to 8 weeks to resolve in this manner. In the rare instances when this fails to resolve the chylous ascites, our interventional radiologists will perform therapeutic lymphography by injecting lipidol, which occludes the lymphatic leak due to its irritating effect on the lymphatic channels. This avoids the theoretical risks of DIC with Denver shunts as well as the most common shunt occlusion complication. Nonetheless, the high success demonstrated in this series of Denver shunts is evidence they have a place in the armamentarium for these difficult refractory cases.