Manual Lymph Drainage and Fascial Release for the Treatment of Chylous Ascites Following Radical Nephrectomy: A Case Report

Abstract

Background: Chylous ascites is “a rare complication of retroperitoneal and mediastinal surgery caused by the unrecognized interruption of major retroperitoneal lymphatic channels and establishment of a lymphoperitoneal fistula.” Chylous ascites occurs 1% to 2% of the time and typically only after surgical injury to the retroperitoneal lymph glands, vessels, or cysterna chyle. Risk factors include manipulation of the para-aortic and superior mesenteric artery root areas, retroperitoneal invasion, focal chronic pancreatitis, having more than 32 lymph nodes removed, several positive lymph nodes, and early enteral feeding. Case Description: Six weeks postradical nephrectomy with complete lymphadenectomy of the periaortic nodes, a 60-year-old otherwise healthy, independent woman was found to have a high-volume chylous ascites. The leakage was attempted to be controlled by a low-fat diet, but she still required 4 paracentesis procedures to remove chylous fluid from her abdomen. Total parenteral nutrition was advised, and the patient declined and referred herself to physical therapy. Other than diet restrictions, she was active and had no functional deficits. Clinical Impression: It had been 6 months since her nephrectomy with lymphadenectomy, it was probable that there was fascial restriction that was preventing closure of the lymphatic vessel wound and allowing chyle to continually leak into the abdomen. Intervention: The chylous ascites was addressed by physical therapy with manual lymph drainage to facilitate the evacuation of fluid out of the abdomen plus fascial releases to mobilize adhesions that may have been impacting the healing of the deep abdominal lymphatic vessels. Measurements and Results: Upon initial examination, her abdomen measured 102 cm at the umbilicus and had multiple large pockets of fluid on the ultrasound scan. On her fourth visit 16 days later, her abdomen measured 81 cm with no appreciable pockets of fluid noted. An 8-week follow-up visit revealed no return of fluid in the abdomen. She was able to return to a normal diet. Discussion: Further research is warranted to determine if fascial release and manual lymph drainage is a viable treatment of chylous ascites.