Management Of Chylous Ascites Research Articles

Successful management of chylous ascites after living donor liver transplantation with somatostatin

Chylous ascites is a rare complication following liver transplantation. A variety of treatment options have been proposed for the management of chylous ascites; however, their effectiveness following a liver transplant is unknown. A 40-year-old woman who underwent living donor liver transplantation for primary biliary cirrhosis developed chylous ascites 21 days after the transplant. A conventional treatment consisting of a low-fat diet with total parenteral nutrition failed to treat the complication for 104 days. However, the use of somatostatin in combination with total parenteral nutrition resulted in a rapid falloff in chyle output without any adverse effects. Somatostatin and total parenteral nutrition are an effective option for the treatment of chylous ascites after living donor liver transplantation.

Management of Chylous Ascites after Laparoscopic Cholecystectomy Using Minimally Invasive Techniques: A Case Report and Literature Review

Chylous ascites is a rare complication after many abdominal procedures. It has never been reported after laparoscopic cholecystectomy. We describe a 31-year-old female who presented 2 weeks postoperatively after laparoscopic cholecystectomy with abdominal distention and pain. A percutaneously drained abdominal fluid collection revealed chylous ascites. Lymphoscintigraphy demonstrated extravasation at the level of the hepatic fossa. At laparoscopic exploration, a chylous leak within the gallbladder fossa was controlled with suture ligation and fibrin glue with immediate resolution of the leak. This demonstrates a novel, minimally invasive technique for control of a previously unreported complication after laparoscopic cholecystectomy.

Chylous Ascites Following Surgical Treatment for Wilms Tumor

Postoperative chylous ascites is a rare complication of retroperitoneal surgery that has considerable morbidity. We review the pathogenesis and management of chylous ascites following surgical treatment of Wilms tumor. We identified 9 children with chylous ascites after surgical treatment of Wilms tumor. Of these cases 3 were treated at a single institution during the last 20 years and 6 were identified during retrospective chart reviews of patients enrolled in National Wilms Tumor Studies 3 and 4 to identify surgical complications. Chylous ascites presented as increased abdominal girth and poor feeding. Paracentesis or laparotomy was diagnostic. Patient age at presentation with Wilms tumor ranged from 6 to 95 months (median 15). Left nephrectomy was performed in 5 cases, right nephrectomy in 3, and left nephrectomy and partial right nephrectomy in 1 with bilateral disease. Lymphadenectomy including the hilar and periaortic lymph nodes was performed in 5 patients, 4 of whom also underwent some form of suprahilar lymph node dissection. Three patients underwent lymph node sampling of the hilar, periaortic and some suprahilar lymph nodes. All children received adjuvant chemotherapy and 4 were treated with adjuvant irradiation to the surgical bed before the diagnosis of chylous ascites. The interval between surgery and diagnosis of ascites ranged from 12 to 49 days (median 21). Of the patients 7 were successfully treated with conservative measures, total parenteral nutrition and/or a diet containing primarily medium chain triglycerides, and 2 required invasive procedures, including exploratory laparotomy and ligation of disrupted lymphatic vessels or placement of a peritoneovenous shunt. Extensive lymph node dissection, particularly above the level of the renal hilum, appears to be associated with the development of postoperative chylous ascites. The National Wilms Tumor Study guidelines do not require formal lymph node dissection for staging and only lymph node sampling is recommended. Elimination of formal lymphadenectomy along with meticulous ligation of lymphatics should decrease the incidence of this complication. Fortunately, conservative treatment with total parenteral nutrition and/or medium chain triglycerides will remedy the problem in the majority of children.

Combined occurrence of chyloperitoneum and chylothorax after surgery and chemotherapy for Wilms' tumor

Chyloperitoneum is an extremely rare complication of abdominal surgery in children and a combined occurrence of chylothorax and chyloperitoneum after abdominal surgery has never been reported in children. Chylous ascites usually occurs as a result of operative trauma to the thoracic duct, cisterna chyli, or its tributaries. About one third of all patients with chylous ascites after retroperitoneal lymph node dissection also develop secondary chylothorax. Diaphragmatic defects have been shown to be responsible for the occurrence of chylothorax secondary to chyloperitoneum. Congenital diaphragmatic weakness may result in evagination of the peritoneum causing diaphragmatic blebs, the rupture of which results in the movement of the peritoneal fluid into the pleural cavity. In the authors' patient, the rent in the diaphragm that occurred during surgery was probably responsible for the chylothorax. The role of chemotherapy, if any, in the pathophysiology of this complication is unknown. Total parenteral nutrition (TPN) is a simple and effective treatment for postoperative chylous effusions. Surgical treatments such as abdominal exploration for the repair of leaking lymphatics and peritoneovenous shunt should be reserved for patients who fail TPN.

The management of chylous ascites in children

The results of surgical treatment of four children with chylous ascites unresponsive to medical management are presented. Peritoneovenous shunts were inserted in three patients, two of whom had the ascites resolved. The third patient was a 4-year-old girl with widespread mucin-secreting carcinomatosis, the first reported case in the literature combined with chylous ascites, whose shunt failed to relieve the ascites. A review of the literature comprising 92 cases of chylous ascites in children and a proposed scheme of management is presented.

Evaluation and management of chylous ascites.

Twenty-eight cases of chylous ascites occurring over the past 20 years are analyzed for clinical presentation, cause, yield of diagnostic procedure used, and response to therapy. Malignancies were responsible for 21 of 24 adult cases of chyloperitoneum, with lymphomas predominating (13 cases). The dismal prognosis in adult cases (12 patients died within 3 months) shows the need for appropriate diagnostic assessment including early lymph node biopsy or laparotomy, or both, when indicated. Surgery, chemotherapy, or radiation therapy should be instituted promptly except in cases resulting from surgical trauma to lymphatics, which frequently resolve with conservative management. Three of the four pediatric cases of chylous ascites resulted from congenital lymphatic anomalies; the fourth case resulted from operative trauma. Aggressive diagnostic and therapeutic interventions are not warranted in childhood cases of chylous ascites until conservative management (paracentesis, low-fat diet, medium-chain triglyceride supplementation) has failed; neoplasia is rarely implicated and many cases resolve within a few months.