Postoperative Chylous Ascites Research Articles

Lymphatic Chyle Duct Injury and Identification During Laparoscopic Sleeve Gastrectomy Preventing Postoperative Chylous Ascites

We present a case of intraoperative detection of an iatrogenic chyle duct injury during laparoscopic sleeve gastrectomy. The chyle duct injury was identified and managed by ligature, preventing postoperative chylous ascites.

A Case of Robot-Assisted Repair of Lymphatic Fistula with Chylous Ascites Following Robotic Retroperitoneal Lymph Node Dissection

Clinical History: A 47-year-old patient, with a history of testicular tumor treated with chemotherapy and robotic retroperitoneal lymph node dissection, experienced recurrent postoperative chylous ascites despite conservative management. Therefore, decision was made to perform robot-assisted exploration to find the source of chyle leakage and to repair it. Physical Examination: Shifting dullness refers to a sign elicited on abdominal examination for ascites, see: https://en.wikipedia.org/wiki/Shifting_dullness. The patient had this sign on abdominal examination at the time of the intervention, as explained in the video. Diagnosis: Inguinal intranodal lymphography was performed, showing an effusion at the level of the third lumbar vertebral body that was embolized. Intervention: On robot-assisted abdominal exploration, intraperitoneal lymphatic effusion was noted from the left para-aortic region, close to the left renal artery. The lymphatic vessels of greater caliber were then closed with metal clips, until all the major sources of lymph effusion were under control. Next, a continuous suture running over the remaining para-aortic lymphatic tissue was applied. Once the suture was completed, methylene blue was then introduced through the nasogastric tube, with no effusion resulting from the lymphatic tissue at any level in the abdomen. A layer of hemostatic matrix was then added and a tubular drain was placed in the retroperitoneum, with its tip laying on the effusion site. The peritoneum was closed and after a final check of the hemostasis, the robotic trocars were removed and the port sites closed. Follow-Up Outcomes: The drain was removed after 72 hours. Since the intervention, the patient did not experience any further recurrence. In this first description, robotic approach was feasible and efficient in management of postoperative chylous ascites not responding to conservative treatment. The authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. The authors declare that they have not had any commercial associations during the past 3 years that might create a conflict of interest in connection with the video. This study is derived from the “IRCCS Azienda Ospedaliero-Universitaria di Bologna,” and there are no conflicts of interest or obligations resulting from it. Runtime of video: 4 mins 22 secs

Chylous ascites following laparoscopic donor nephrectomy: Report of a case and a brief overview

Postoperative chylous ascites is a well-known complication of retroperitoneal lymph node dissection for testicular malignancies. This complication is now being reported increasingly with laparoscopic nephrectomies as well. A 33-year-old woman with no comorbidities underwent laparoscopic left donor nephrectomy. She had an uneventful postoperative recovery and was discharged on the 5th postoperative day. She reported on the 11th postoperative day with abdominal distension. Clinical examination revealed free fluid in the peritoneal cavity, and she was evaluated further. Imaging revealed mild ascites, which was aspirated, yielding milky fluid. Biochemical analysis of the fluid revealed triglycerides and chylomicrons, consistent with chyle. She was admitted, and an intra-abdominal drain placed under ultrasound guidance. Subsequently, she underwent lymphangiography and embolization. Her drain output came down, and she remained asymptomatic following drain removal. There was no further chylous leak on subsequent follow-up. Chylous ascites following laparoscopic nephrectomy is more common on the left side. Chylous leaks have been attributed to incomplete sealing of lymphatics with energy devices. Precise surgical technique of division of lymphatics between clips can prevent this complication. Most small leaks settle with a conservative care. Those that do not settle require open ligation. Percutaneous lymphatic embolization is an effective minimally invasive modality in managing such patients.

Novel management indications for conservative treatment of chylous ascites after gastric cancer surgery.

Chylous ascites (CA) presents a challenge as a relatively common postoperative complication in gastric cancer (GC). Primary conservative therapy involved total parenteral nutrition, continuous low-pressure drainage, somatostatin, and a low-fat diet. Drainage tube (DT) clamping has been presented as a potential alternative conservative treatment for GC patients with CA. To propose novel conservative treatment strategies for CA following GC surgery. The data of patients with CA after GC surgery performed at the Fudan University Shanghai Cancer Center between 2006 and 2021 were evaluated retrospectively. 53 patients underwent surgery for GC and exhibited postoperative CA during the study period. Postoperative hospitalization and time of DT removal showed a significant positive association (R 2 = 0.979, P < 0.001). We further observed that delayed DT removal significantly extended the total and postoperative hospitalization, antibiotic usage duration, and hospitalization cost (postoperative hospitalization: 25.8 d vs 15.5 d, P < 0.001; total hospitalization: 33.2 d vs 24.7 d, P < 0.01; antibiotic usage duration: 10.8 d vs 6.2 d, P < 0.01; hospitalization cost: ¥9.2 × 104 vs ¥6.5 × 104, P < 0.01). Multivariate analysis demonstrated that postoperative infection and antibiotic usage were independent factors for delayed DT removal. Furthermore, DT removal times were shorter in seven patients who underwent DT clamping (clamped DT vs normal group, 11.8 d vs 13.6 d, P = 0.047; clamped DT vs delayed group, 13.6 d vs 27.4 d, P < 0.001). In addition, our results indicated that removal of the DT may be possible after three consecutive days of drainage volumes less than 300 mL in GC patients with CA. Infection and antibiotic usage were vital independent factors that influenced delayed DT removal in patients with CA. Appropriate standards for DT removal can significantly reduce the duration of hospitalization. Furthermore, DT clamping might be a recommended option for conservative treatment of postoperative CA.

Postoperative chylous ascites after total gastrectomy successfully treated using peritoneovenous (Denver) shunt: a case report

BackgroundChylous ascites (CA) is a rare complication of gastrectomy for gastric cancer. While most cases of postoperative CA improve with medication or nutritional support, some are refractory to conservative treatment. A peritoneovenous shunt (PVS) may help patients who are poor candidates for surgery. However, PVS placement for postoperative CA after gastroenterological surgery has been rarely reported. Herein, we present a case of postoperative CA following total gastrectomy with para-aortic lymphadenectomy, treated successfully by PVS placement.Case presentationA 74-year-old man who underwent total gastrectomy with para-aortic lymph node dissection was hospitalised because of insufficient oral intake and dehydration. His abdomen was markedly distended with severe bilateral lower extremity oedema. On admission, abdominal computed tomography (CT) showed a high volume of ascites and no signs of cancer recurrence. Accordingly, postoperative CA resulting from drainage of fluid on paracentesis was diagnosed. Despite nutritional support, diuretics, and octreotide administration, his abdominal distension and nutritional status did not improve. We could not identify the sites of lymphatic leakage in the three intranodal lymphangiographies followed by CT. Although we considered a surgical treatment in our patient, we decided against it. Because we could not identify lymphatic leakage site during lymphangiography, surgical treatment might have a potential failure of detection and closure of leakage site. Furthermore, the patient’s general condition was poor because of malnutrition resulting from the loss of lymphatic fluid. Consequently, we decided to place PVS. After PVS placement, his abdominal distension improved rapidly, and he was discharged without serious complications. Thirteen months after PVS, patient has no relapse of abdominal distention and nutrition status has improved.ConclusionPVS might be a good option to manage refractory postoperative CA, as the leakage point cannot be detected on lymphangiography.

Chylous ascites has a higher incidence after robotic surgery and is associated with poor recurrence-free survival after rectal cancer surgery.

Background:Postoperative chylous ascites is an infrequent condition after colorectal surgery and is easily treatable. However, its effect on the long-term oncological prognosis is not well established. This study aimed to investigate the short-term and long-term impact of chylous ascites treated with neoadjuvant therapy followed by rectal cancer surgery and to evaluate the incidence of chylous ascites after different surgical approaches.Methods:A total of 898 locally advanced rectal cancer patients treated with neoadjuvant chemoradiotherapy followed by surgery between January 2010 and December 2018 were included. The clinicopathological data and outcomes of the patients with chylous ascites were compared with those of the patients without chylous ascites. The primary endpoint was recurrence-free survival (RFS). To balance baseline confounders between groups, propensity score matching (PSM) was performed for each patient with a logistic regression model.Results:Chylous ascites was detected in 3.8% (34/898) of the patients. The incidence of chylous ascites was highest after robotic surgery (6.9%, 6/86), followed by laparoscopic surgery (4.2%, 26/618) and open surgery (1.0%, 2/192, P = 0.021). The patients with chylous ascites had a significantly higher number of lymph nodes harvested (15.6 vs. 12.8, P = 0.009) and a 3-day longer postoperative hospital stay (P = 0.017). The 5-year RFS rate was 64.5% in the chylous ascites group, which was significantly lower than the rate in the no chylous ascites group (79.9%; P = 0.007). The results remained unchanged after PSM was performed. The chylous ascites group showed a nonsignificant trend towards a higher peritoneal metastasis risk (5.9% vs. 1.6%, P = 0.120). Univariate analysis and multivariate analysis confirmed chylous ascites (hazard ratio= 3.038, P < 0.001) as an independent negative prognostic factor for RFS.Conclusions:Considering the higher incidence of chylous ascites after laparoscopic and robotic surgery and its adverse prognosis, we recommend sufficient coagulation of the lymphatic tissue near the vessel origins, especially during minimally invasive surgery.

Chylous ascites after complete mesocolic excision for right-sided colon cancer with D3 lymphadenectomy: Aretrospective cohort-study.

This retrospective study was designed to evaluate risk factors of the occurrence and severity of chylous ascites after complete mesocolic excision (CME) and D3lymphadenectomy in patients with right-sided colon cancer. Consecutive patients receiving CME and D3lymphadenectomy for right-sided colon cancer were included. Risk factors of the occurrence and severity of chylous ascites by using logistic analysis were assessed. A nomogram predicting chylous ascites was constructed. Among 661 patients included in the study, postoperative chylous ascites occurred in 48 (7.3%) patients. Logistic regression analysis demonstrated that prognostic nutritional index (PNI≤47, OR=2.172, p=0.016), laparoscopic surgery (OR=2.798, p=0.034), operating time (>225min, OR=2.645, p=0.002), and apical lymph node (APN) metastasis (OR=3.698, p=0.034) were correlated with the occurrence of postoperative chylous ascites. A nomogram predicting postoperative chylous ascites was constructed (C-index 0.701). 31.2% (15/48) of patients with chylous ascites were resolved in more than 7days. The number of retrieved lymph nodes (OR=1.074, 95% CI: 1.002-1.152, p=0.044) and PNI≤47 (OR=7.890, 95% CI: 1.224-50.869, p=0.030) were independently predictive of prolonged chylous ascites resolution (≥7days). In our series, 7.3% of patients developed chylous ascites after right hemicolectomy with CME and D3 lymphadenectomy. Laparoscopic surgery, PNI, operation time, and APN metastasis were independently predictive of postoperative chylous ascites. Lower PNI and more retrieved lymph nodes were correlated with prolonged resolution of chylous ascites.

Prediction of prolonged resolution of chylous ascites after radical D3 resection for colorectal cancer: A population-based experience from a high-volume center

AimThis study was aimed to analyze the incidence, risk factors, and management of chylous ascites (CA) after radical D3 resection for colorectal cancer, and to construct a predicting nomogram for prolonged resolution of CA. MethodConsecutive colorectal cancer patients who underwent radical D3 resection were included. Logistic analysis was used to identify risk factors of postoperative CA, as well as prolonged CA resolution. A predictive nomogram for prolonged resolution of CA was developed and validated internally. ResultsAmong 7167 patients included, 277 (3.8%) patients developed CA. Logistic regression analysis demonstrated that laparoscopic operation (OR 1.507; P = 0.017) and tumors fed by the superior mesenteric artery (SMA, OR 2.456; P < 0.001) were independent risk factors of postoperative CA following radical D3 surgery for colorectal cancer. Open operation (OR 0.422; P = 0.027), drainage output on the first day of treatment (OR 1.004; P = 0.016), time to oral intake (OR 1.273; P = 0.042), and time to onset (OR 1.231; P = 0.024) were independently associated with prolonged resolution of postoperative CA (≥7 days). A predictive nomogram for prolonged CA resolution was developed with a C-index of 0.725. ConclusionThe incidence of CA after radical D3 surgery of colorectal cancer was 3.8%. Open operation, drainage output on the first day of treatment, time to oral intake, and time to onset were independently associated with prolonged resolution of postoperative CA. A nomogram may assist in tailored treatment decision-making and counseling patient with treatment strategies.

Postoperative Chylous Ascites: Application of Interventional Techniques

Moderate sedation in interventional radiology (IR) relies on registered nurses (RNs) with specific education to ensure the best patient outcomes. Research conducted during the previous decades has improved the understanding of nursing labor quality and the relationship to outcomes; yet, there is limited description related to specialty practice areas. Defining parameters for IR nursing allows the study of nurse-driven outcomes for patients receiving sedation. A 26-question survey was sent to a national sample of radiologic administrators (n=510). Statistics included frequency distributions, means, standard deviations, medians, interquartile ranges, chi-square and Mann-Whitney tests; statistical significance p<.05. The response rate was 16% (n = 82). Annual moderate sedation training for RNs was required at most institutions (94.9% 75 of 79) with variation in methods of delivery. Basic life saving (100%, 77 of 77) and advanced cardiac life saving (97.4%, 75 of 77) were primarily required; less than a fifth (17.9%, 10 of 56) noted critical care nursing, or certified radiology nurse certification (7.4%, 4 of 54). A BSN was the most commonly reported degree (median 60% of RNs, IQR = 45.8, 86.1). There is variation in how moderate sedation training is accomplished, its complexity, and the required degree attainment of nurses who participate in the administration of moderate sedation. These findings reflect the limited consensus statements available regarding competencies for moderate sedation nursing practice. Continued studies of moderate sedation and the workforce in IR is essential to understand the RN role in achieving high-quality, safe patient care.

Conservative management of chylous leak after open radical nephrectomy in an adult patient: a case report and literature review

BackgroundChylous ascites is rare but still a recognized complication of retroperitoneal surgeries caused mostly by inadvertent trauma to lymphatic channels. In this article, we present a case report and literature review of adult patient, with malignant tumor of upper urinary tract, who developed chylous leak after open nephrectomy.Case presentationWe present a case of chylous leak for a 67-year-old female patient, presented to urology clinic with complaining of left loin pain and gross hematuria, found to have upper urinary tract tumor, she underwent open radical nephrectomy with lymph nodes dissection, and postoperatively she had chylous leak that is treated conservatively using octreotide and spironolactone without the need for total parenteral nutrition.ConclusionConservative management should always be the first choice of management of chylous leak and chylous ascites. Careful anatomical identification and securing of the periaortic lymphatics are needed to decrease the risk of postoperative chylous leak and ascites.

Therapeutic lymphangiography for refractory post-operative chylous ascites in children: Can a needle replace the knife?

Chylous ascites is a rare but well-known complication following surgeries involving extensive dissection of the retroperitoneal structures. It is noticed in children primarily after oncological resections. Meanwhile, conservative treatment is paramount in its management; refractory cases generally require an aggressive approach. A rare case of refractory chylous ascites in a two-year-old boy occurring after excision of recurrent retroperitoneal neuroblastoma is being reported. The child underwent therapeutic lymphangiography with ethiodized oil, as an alternative to surgery, to tackle the refractory post-operative chyle leak. A prompt response was noticed and no recurrence of ascites has been observed during a 15-month follow-up.

Chylous Ascites and Lymphoceles: Evaluation and Interventions.

Kinmonth introduced lymphangiography in 1955 and it became an important tool in the diagnosis and treatment of malignant disease. The technique, based on bipedal approach, was difficult and time-consuming which limited its use in clinical practice. Cope is the father of percutaneous lymphatic interventions and he was the first person to access and intervene on the lymphatic system. After his initial work published on 1999, there has been an expansion of the lymphatic embolization techniques, particularly since the development of intranodal lymphangiography and advance lymphatic imaging. This article is focused on the evaluation and management of postoperative chylous ascites and lymphoceles. Their incidence is growing due to longer survival of cancer patients and more radical surgical approaches, leading to an increased morbidity and mortality in this patient population. Minimally invasive percutaneous lymphatic embolization is becoming a first-line therapy in patients with postoperative lymphatic leakage.

Využití radioterapie v léčbě pooperačního chylózního ascitu

Chylozni ascites - hromaděni chylozni tekutiny bohate na triglyceridy v dutině břisni nasledkem traumatu ci obstrukce lymfatických cest - je poměrně vzacný jev. Nejcastějsi přicinou u dospělých je malignita (hepatocelularni karcinom, diseminace primarnich tumorů - karcinom prsu, pankreatu, colon, ovarii, varlat, ledvin, dale lymfom tenkeho střeva, retroperitonealni lymfomy), cirhoza jater nebo traumaticke poskozeni při výkonech v oblasti retroperitonea. Lecba je velmi individualni, založena zejmena na nutricni podpoře a terapii primarni přiciny. Pokud konzervativni lecba selže, lze přistoupit ke specialnim terapeutickým zasahům - např. chirurgicke řeseni, somatostatinova analoga, embolizace lymfatických cest, radioterapie. Popisujeme kazuistiku pacientky, u niž vznikl chylozni ascites po radikalnim onkogynekologickem výkonu.

Lymphangiography with or without Embolization for the Treatment of Postoperative Chylous Ascites

Lymphatic interventions have recently been increasingly used for treating lymphatic leak of the abdomen and pelvis. This retrospective case study series and systematic review evaluated the efficacy and safety of lymphatic interventions for the treatment of postoperative lymphatic leak of the abdomen and pelvis. A total of 15 consecutive patients with postoperative lymphatic leak of the abdomen and pelvis treated with lymphatic interventions (i.e., diagnostic intranodal or pedal lymphangiography [LAG], i.e., potentially therapeutic or diagnostic LAG with intention to treat through embolization) at our institution were reviewed. The data of 72 patients from 13 relevant articles identified through a literature search of the MEDLINE/PubMed, EMBASE, and Cochrane databases were extracted. The data of 87 patients (mean age, 59 [range, 24-84] years) were pooled. The technical success rate of LAG (intranodal approach, 78.2% [68/87]; pedal approach, 21.8% [19/87]) was 97.7% (85/87; 95% confidence interval [CI], 91.5-99.9%). Of the 85 patients in whom technical success of LAG was achieved, data on clinical success were available for 47 patients (55.3%). The clinical success rate of LAG was 68.1% (32/47; 95% CI, 53.8-79.7%). Of the 85 patients in whom technical success of LAG was achieved, 38 (44.7%) underwent embolization. The technical success rate of embolization was 97.4% (37/38; 95% CI, 85.3-99.9%). The clinical success rate of embolization was 70.3% (26/37; 95% CI, 54.1-82.6%). Major complications did not occur. The overall primary and secondary clinical success rates were 65.5% (57/87; 95% CI, 55.0-74.7%) and 78.2% (68/87; 95% CI, 68.3-85.6%), respectively. Lymphatic interventions are safe and relatively effective adjunct to conservative therapy, with the primary and secondary clinical success rate of 65.5% and 78.2%, for postoperative lymphatic leak of the abdomen and pelvis.

The retrospective research of enteral nutrition with medium-chain triglyceride and total parenteral nutrition support of postoperative chylothorax in adults.

Background:Chylothorax is caused by thoracic lymphatic system injuries that leads to the lymph extravasating into the thoracic cavity. There are few reports comparing the therapeutic effects of enteral nutrition with medium-chain triglyceride and total parenteral nutrition, and the results are inconsistent. Our study aimed to research the optimum nutrition support method for chylothorax.Study design:We retrospectively reviewed 35 chylothorax patients after heart and chest surgery from 2014 to 2018, at West China Hospital of Sichuan University, among them there were 27 post-heart surgery patients. We analyzed the therapeutic effects and costs of enteral nutrition with medium-chain triglyceride (E group) and total parenteral nutrition (T group) for chylothorax.Results:The results were similar in patients with all surgeries and patients with only post heart surgery. The total cost during hospitalization in E group was higher than T group (P < 0.01), whereas the nutrition support cost was lower (P < 0.001). The length of hospital stay was longer in E group than T group (P > 0.05). Time from admission to surgery was shorter and from surgery to chylothorax diagnosis was longer in E group compared with T group. Time to resolution and removal of drainage was shorter in E group than T group but the differences were not significant.Conclusion:The therapeutic effects in enteral nutrition with medium-chain triglyceride and total parenteral nutrition had no obvious differences. Moreover, enteral nutrition with medium-chain triglyceride is safer and more economical. Therefore, we suggest that enteral nutrition with medium-chain triglyceride could be the first choice to treat postoperative chylothorax when the gastrointestinal tract function is allowed, and this result could be considered for postoperative chylous ascites.

Diagnosis, Outcome, and Management of Chylous Ascites Following Pediatric Liver Transplantation.

Data on postoperative chylous ascites (CA) after pediatric liver transplantation (LT) are scarce. This retrospective study was conducted to identify the incidence, risk factors, management, and outcomes of postoperative CA in a large single‐center pediatric LT cohort (2000‐2016). The study cohort comprised 317 LTs (153 living donors and 164 deceased donors) in 310 recipients with a median age of 2.7 years. The incidence of CA was 5.4% (n = 17), diagnosed after a median time of 10 days after LT. Compared with chylomicron detection in peritoneal fluid (the gold standard), a triglyceride cutoff value of 187 mg/dL in peritoneal fluid showed insufficient sensitivity (31%) for CA diagnosis. In univariate logistic regression analyses, ascites before LT, younger age, and lower weight, height, and height‐for‐age z score at LT were associated with CA. Symptomatic management of CA included peritoneal drain (100%) and diuretics (76%). Therapeutic interventions included very low‐fat or medium‐chain triglyceride–rich diets (94%) and intravenous octreotide (6%), leading to CA resolution in all patients. CA was associated with prolonged hospital length of stay (LOS; 40 days in the CA group versus 24 days in the non‐CA group; P = 0.001) but not with reduced patient or graft survival rates after a median follow‐up time of 14 years. In conclusion, CA in the pediatric LT recipient is a relatively uncommon complication associated with increased hospital LOS and morbidity. Measurement of chylomicrons is recommended in patients with ascites that is more severe or persistent than expected. Dietary interventions are effective in most patients.

CONSERVATIVE MANAGEMENT OF CHYLOUS ASCITES AFTER ONCOLOGICAL SURGERY FOR PERIPHERAL NEUROBLASTIC TUMORS IN PEDIATRIC PATIENTS

Chylous ascites may complicate the postoperative course of abdominal surgery mainly due to the iatrogenic disruption of the lymphatic channels during extensive retroperitoneal dissection. Sparse data are available regarding treatment; however, in many cases a recommended first-line treatment approach is by way of enteral feeding, consisting of a formula high in medium-chain triglycerides (MCTs) together with a complete total parenteral nutrition teamed with somatostatin (or an equivalent). Nonetheless, the ligation of chylous fistulae, together with the application of Fibrin glue, as well as the creation of peritoneal-venous shunts have also been documented. The aims of this study are to document incidence of postoperative chylous ascites following resection of abdominal peripheral neuroblastic tumors, evaluate efficacy of the management of chylous ascites, and investigate the main risk factors. A survey was carried out over a span of six years, from March 2010 to March 2016 at Giannina Gaslini Children's Hospital involving seventy-seven children with resections of peripheral neuroblastic tumors. Incidence rate of postoperative chylous ascites following a normal diet was 9% (n=7). Treatment using total parenteral nutrition with octreotide resulted in a complete recovery from chylous ascites within a 20 day period without recurrence. Length of operative time, nephrectomy, and the extension of lymphadenectomy were all significantly associated with a higher incidence of postoperative chylous ascites (p<0.05) which also lengthened hospital stay (p<0.05) and possibly delayed beginning adjuvant chemotherapy.

Management of postoperative chylous ascites after surgery for ovarian cancer: a single-institution experience.

Postoperative chylous ascites is a rare complication from operative trauma to the cisterna chyli or lymphatic vessels in the retroperitoneum. In the present study, we aimed to identify the incidence of postoperative chylous ascites in patients treated for ovarian cancer and to describe its management. We retrospectively reviewed all patients submitted to surgery for ovarian cancer at our Institution from October 2016 to November 2018. We analyzed the clinicopathological features, including the primary tumor histology, stage, grade, surgical procedure, median number of harvested pelvic and para-aortic lymph nodes. We described our experience in the diagnosis and management of chylous ascites. Five hundred and forty-six patients were submitted to surgery for ovarian cancer and 298 patients received pelvic and/or para-aortic lymphadenectomy. Chylous ascites occurred in 8 patients with an incidence of 1.4% in the overall population and a 2.68% among patients receiving lymphadenectomy. All patients received total parenteral nutrition (TPN) with Olimel N4E 2000mL (Baxter®) and somatostatin therapy with 0.2mL per 3 times/day for a median of 9days (range 7-11). Median hospital stay was 15days (range 7-16). All patients were successfully managed conservatively and none required surgical correction. Conservative management of chylous ascites with TPN, somatostatin and paracentisis is feasible and effective. These data should be confirmed by prospective multicentric studies.

Low-Dose Radiation Therapy is an Effective Treatment for Refractory Postoperative Chylous Ascites: A Case Report

PurposeWhen lymphatic pathways are disrupted via obstruction or traumatic injury, a temporary or chronic chyle leak may result, which is defined as the presence of chyle that collects outside of the lymphatic vessels within the thoracic or abdominal cavities. For a chyle leak that is refractory to surgical repair, no good options exist. Radiation therapy (RT) can result in scarring and fibrosis of the lymphatic fistula. We report on the first clinical case in the United States with the successful use of low-dose (LD) RT in the management of refractory chylous ascites. Methods and MaterialsA 74-year-old man developed significant chylous ascites after a laparoscopic Nissen fundoplication. After failure of numerous conservative and surgical interventions, he was referred for radiation medicine. We delivered a dose of 10 Gy in daily 1 Gy fractions to the para-aortic region, including the cisterna chyli and thoracic duct from T12 to L2. ResultsThe patient tolerated LD-RT well with no toxicity. By the time of the 8-month post-RT follow-up visit, he had decreased chylous ascite levels and required no paracentesis or peritoneovenous shunting. There was no evidence of chylous ascites or recurrent chyle leak at the time of the 18-month follow-up visit. ConclusionsLD-RT for refractory postoperative chylous ascites is a safe and reasonable option that can provide temporary relief in addition to other conservative methods. This is the first reported case of refractory chylous ascites in the United States that was successfully treated with LD-RT.

Usefulness of the milk test to prevent chylous ascites after pancreatectomy

Introduction: The usefulness of the milk test to prevent chylous ascites after pancreatectomy was investigated using a randomized controlled trial. Method: The milk test involves injecting 100 mL milk through a nasogastric tube during pancreatectomy. If a chyle leak is present, the patient tests positive. Drain triglyceride (DTG) was measured on the first and third postoperative day (POD). Results: From November 2013 to June 2017, 253 patients were enrolled; 211 patients underwent pancreatic head resection, 39 underwent distal pancreatectomy, and 3 underwent middle pancreatectomy. The milk test was used in 125 patients (group A) and not used in 128 patients (group B). In group A, the milk test was positive in 29 patients (23.2%). The superior mesenteric artery (11 patients) and middle colic artery (10 patients) were common leakage sites. The incidence of postoperative chylous leaks defined by the ISGPS was on Table 1.Tabled 1TableChyle leakGroup A milk test positiveGroup A milk test negativeGroup BTotalNone2193116230Grade A731020Grade B1023Grade C0000Total2996128253 Open table in a new tab Chylous ascites occurred in 3 patients (1.2%), all during pancreatic head resection. In group B, grade B chyle leaks were observed twice as often as in group A, but the difference was not significant. DTG levels on POD 1/POD 3 were 123.9/83.5 in milk test-positive patients and 63.2/47.1 in milk test-negative patients in group A, 52.8/52.3 in group B patients, 58.1/42.4 in the no chyle leak patients, 144.3/186.9 in grade A and 73.3/62.3 in grade B patients. Conclusion: DTG level was not a predictor of postoperative chylous ascites. Without the milk test, Grade B chyle leaks occurred twice as often, but this was not statistically significant.