A Rare Cause of Chylous Ascites

Abstract

Purpose: A 47-year-old female underwent laparoscopic living donor nephrectomy (LLDN) without intraoperative complications. One week postoperatively, she presented with increasing abdominal distention and pain. Her physical exam revealed normal vital signs and a positive fluid wave. Complete blood counts and a comprehensive metabolic profile were within normal limits. A CT scan of the abdomen revealed moderate ascites, and an ultrasound guided paracentesis aspirated milky fluid with a SAAG of < 0.1 g/dL. Fluid analysis demonstrated an elevated triglyceride level of 2,416 mg/dL, with a normal amylase, lipase, glucose, gram stain, and culture. A diagnosis of chylous ascites (CA) was made, and conservative management with total parentral nutrition (TPN), furosemide, and subcutaneous octreotide was initiated. She continued to have significant ascites despite medical therapy and dietary modification. She subsequently underwent laparoscopic cholecystectomy for symptomatic cholecystitis with retroperitoneal exploration. The damaged lymphatics were identified and ligated. Postoperatively, octreotide and TPN were discontinued and a diet was restarted. The ascites resolved shortly thereafter, and she has remained asymptomatic. CA is an exceptional rare, though serious, complication of LLDN with only several reported cases in the literature. The mechanism is postulated to be a disruption of the retroperitoneal lymphatic channels located in proximity to the renal hilum at the time of surgery. The most common etiology of CA is malignancy and underlying cirrhotic liver disease. Further innovations in surgical techniques have allowed for more invasive procedures, resulting in a rise of CA as a complication of retroperitoneal interventions. The treatment of CA has focused on decreasing lymphatic flow in the retroperitoneum and the underlying stimulation of lymph production. Subcutaneous octreotide has been shown to decrease lymph flow and is used in combination with limiting nutrition to TPN and medium chain fatty acids (MCFA). Medical therapy fails 40-50% of the time, and surgical intervention is often needed, as multiple paracenteses cause protein malnutrition and loss of lymphocytes. Laparoscopic interventions using ligation of lymphatics and glue are often required to treat a localized leak. CA is a rising complication of retroperitoneal interventions, and we suggest that patients be counseled regarding the potential for development of CA when undergoing LLDN.