Nutritional support in adults with chyle leaks

We provide a practical approach to the complex management problem of chyle leaks that occur after surgical procedures or trauma, or when they occur spontaneously in association with malignancies. The volume of chyle loss causes significant problems due to loss of fluid, electrolytes, proteins, and lymphocytes, causing deleterious effects on wound healing and immunity. Enteral feeding is not always possible as long chain fatty acids are absorbed through the intestinal lacteals, the original source of chyle. Regular diets increase the leak and delay healing. Nutritional support involves coordinated care between healthcare providers to provide a combination of various modalities, including nil by mouth, parenteral nutrition, enteral feeding with formula modifications, and oral diet.

Surgical repair of intractable chylous ascites following laparoscopic anterior resection

Chylous ascites is the accumulation of a milk-like peritoneal fluid rich in triglycerides and it is an unusual complication following surgical treatment of colorectal cancer. Conservative management is usually sufficient in patients with chylous ascites after surgery. However, we describe a patient with intractable chylous ascites after laparoscopic anterior resection for sigmoid colon cancer who failed initial conservative treatment. This patient was successfully managed by surgery.

Incidence and risk factors of chylous ascites after pancreatic resection

Chylous ascites (CA) is a rare postoperative complication. It also occurs in pancreatic surgery and can influence the patient's prognosis after pancreatic resection. There are few studies focusing on CA following pancreatic resection. We aimed to evaluate the incidence and risk factors of CA following pancreatic resection. Patients who underwent pancreatic resection from the year 2007 to 2013 were retrospectively reviewed. The diagnosis of CA was based on the presence of a non-infectious milky or creamy peritoneal fluid greater than 100 ml/day with a triglyceride concentration ≥110 mg/dl. The incidence and possible risk factors following pancreatic resection were evaluated. In this study, 1921 patients who underwent pancreatic resection were included. 49 patients developed CA. The overall incidence was 2.6 percent (49 out of 1921). The incidence following pancreaticoduodenectomy and distal pancreatectomy was much higher (35 out of 1241, 12 out of 332, respectively). A multivariable analysis demonstrated that manipulating para-aortic area and superior mesenteric artery root area; retroperitoneal invasion; focal chronic pancreatitis and early enteral feeding were the independent risk factors for CA after pancreatic surgery. In conclusion, CA is a rare complication after pancreatic resection. Some clinicopathological factors were associated with the development of CA following pancreatic resection.

Small-volume chylous ascites after laparoscopic radical gastrectomy for gastric cancer: Results from a large population-based sample

AIM: To report the incidence and potential risk factors of small-volume chylous ascites (SVCA) following laparoscopic radical gastrectomy (LAG).

METHODS: A total of 1366 consecutive gastric cancer patients who underwent LAG from January 2008 to June 2011 were enrolled in this study. We analyzed the patients based on the presence or absence of SVCA.

RESULTS: SVCA was detected in 57 (4.17%) patients, as determined by the small-volume drainage (range, 30-100 mL/24 h) of triglyceride-rich fluid. Both univariate and multivariate analyses revealed that the total number of resected lymph nodes (LNs), No. 8 or No. 9 LN metastasis and N stage were independent risk factors for SVCA following LAG (P < 0.05). Regarding hospital stay, there was a significant difference between the groups with and without SVCA (P < 0.001). The 3-year disease-free and overall survival rates of the patients with SVCA were 47.4% and 56.1%, respectively, which were similar to those of the patients without SVCA (P > 0.05).

CONCLUSION: SVCA following LAG developed significantly more frequently in the patients with ≥ 32 harvested LNs, ≥ 3 metastatic LNs, or No. 8 or No. 9 LN metastasis. SVCA, which was successfully treated with conservative management, was associated with a prolonged hospital stay but was not associated with the prognosis.

Lymphangiography to treat postoperative lymphatic leakage: a technical review

In addition to imaging the lymphatics and detecting various types of lymphatic leakage, lymphangiography is a therapeutic option for patients with chylothorax, chylous ascites, and lymphatic fistula. Percutaneous thoracic duct embolization, transabdominal catheterization of the cisterna chyli or thoracic duct, and subsequent embolization of the thoracic duct is an alternative to surgical ligation of the thoracic duct. In this pictorial review, we present the detailed technique, clinical applications, and complications of lymphangiography and thoracic duct embolization.

Chylous ascites treated by traditional Chinese herbal medicine: a case report and discussion

Chylous ascites, which can lead to peritonitis, intestinal obstruction, metabolic disorder, and even death from pyemia, is a rare complication of abdominal surgery. Currently, first-line treatment involves conservative management, which includes oral diet and total parenteral nutrition (TPN). However, the efficacy of these treatments cannot be guaranteed. For example, single diet control can result in consecutive drainage for up to 1 month, and salvage surgery is required for some invalid cases. Here, we report 6 cases of chylous ascites after abdominal surgery. In addition to diet control, we delivered traditional Chinese herbal medicine (TCHM) twice daily orally. The drainage volume of the chylous fistula showed an obvious decrease 1 day after the TCHM administration and all 6 patients completely recovered within 4 to 8 days (median: 5.5 days). Although relevant data are limited, our cases would suggest that TCHM could play an important role in the management of chylous ascites. However, randomized controlled trials are still needed to confirm its efficacy in a larger population.

Chylothorax and chylous ascites: management and pitfalls

Leakage of lymph from the lymphatic ducts causes chylothorax (CT) or chylous ascitis (CA). This may happen for unknown reasons during fetal life or after birth and may also be caused by trauma after thoracic surgery or by other conditions. Fetal CT and CA may be lethal particularly in cases with fetal hydrops that sometimes benefit of intra-uterine instrumentation. After birth, symptoms are related to the amount of accumulated fluid. Sometimes, severe cardio-respiratory compromise prompts active therapy. Most patients with CT or CA benefit from observation, rest, and supportive measures alone. Drainage of the fluid may be necessary, but then loss of protein, fat, and lymphoid cells introduce new risks and require careful replacement. Low-fat diets with MCT and parenteral nutrition decrease fluid production while allowing adequate nutritional input. If lymph leakage does not stop, secretion inhibitors like somatostatin or octreotide are prescribed, although there is only weak evidence of their benefits. Imaging of the lymphatic system is indicated when the leaks persist, but this is technically demanding in children. Shunting of the lymph from one body space to another by means of valved catheters, embolization of the thoracic duct, and/or ligation of the major lymphatics may occasionally be indicated in cases refractory to all other treatments.

Midgut volvulus presenting with acute chylous peritonitis

Key Clinical message

Midgut volvulus can rarely present with acute chylous peritonitis. Common etiologies for chylous ascites need to be excluded before this diagnosis is made. Correction of the volvulus and peritoneal lavage suffice as treatment.

Simultaneous chylothorax and chylous ascites due to tuberculosis

Chylothorax or chylous ascites is rare manifestation of tuberculosis. We report a case of simultaneous chylothorax and chylous ascites due to tuberculosis. A 17-year-old girl was admitted with fever, abdominal distention and dyspnea. Chest and abdominal computed tomography revealed bilateral pleural effusion, multifocal nodular consolidation on both lung fields and copious ascites and multiple necrotic lymphadenopathy in the abdominal cavity. Mycobacterium tuberculosis was isolated from sputum and pleural fluid. The patient was treated with anti-tuberculosis medication. Pleural effusion and ascites improved with the medication.

Chylous ascites as a complication of laparoscopic colorectal surgery

INTRODUCTION

Until now, no data have been available on the incidence of chylous ascites after laparoscopic colorectal surgery.

METHODS

From January 2007 to December 2011, 137 patients with colorectal cancer underwent laparoscopic surgery at our institution. The clinical data of the patients with postoperative chylous ascites were compared with those of the patients without chylous ascites.

RESULTS

Chylous ascites developed in 9 of the 137 patients (6.5%). Blood loss, operative time, tumor location, and extent of lymph node dissection were not associated with postoperative chylous ascites. Mean postoperative hospital stay for patients with chylous ascites was significantly longer than that for patients without any complications (14 days vs 10 days; P < 0.001). Recurrence was observed in two of the nine patients with chylous ascites; it developed locally and in the liver in one patient, and peritoneal dissemination was seen in the other. The recurrence rate in the chylous ascites group (22.2%) was significantly higher than that in the non-chylous ascites group (3.9%; P = 0.016). The 3-year disease-free survival in the chylous ascites group (76.2%) was significantly lower than that in the non-chylous ascites group (93.4%; P = 0.020); however, the 3-year overall survival rates did not differ between the groups (87.5% vs 94.4%, respectively; P = 0.332).

CONCLUSION

Chylous ascites are not a rare complication of laparoscopic colorectal surgery. It was managed conservatively in all cases but was associated with longer hospital stays. We recommend careful tissue dissection at a suitable plane and meticulous clipping during lymphadenectomy to prevent chyle leakage when lymphatic invasion is suspected.

Incidence and risk factors of chylous ascites after colorectal cancer surgery

BACKGROUND

The aim of this study was to identify possible risk factors associated with chylous ascites after colorectal cancer surgery.

METHODS

Patients who underwent colorectal cancer resection were enrolled in this study. Data were compared between patients who developed chylous ascites and those who did not.

RESULTS

Chylous ascites was detected in 48 (6.6%) patients. There were significant differences between the groups with and without chylous ascites in terms of age (65.6 vs 61.6 years, P = .017), operator (5.0% vs 15.5%, P < .001), operative procedure based on tumor location (P = .041), operative time (206.0 vs 229.8 minutes, P = .045), and blood loss (78.1 vs 219.7 mL, P = .036). After subgroup analysis for right-sided colectomy and low anterior resection to compensate for the effects of the operative procedure, the differences in the operative time and blood loss were not significant. In most patients, chylous ascites was resolved with conservative management.

CONCLUSIONS

Chylous ascites developed significantly more frequently in patients who underwent right-sided colectomy and in elderly patients. In addition, the incidence was also dependent on the operator. Conservative treatment was effective in most patients.

Chylous ascites after laparoscopic hand-assisted donor nephrectomy: Is it specific for the left-side?

We describe a case-report of a chylous ascites after laparoscopic donor nephrectomy, summarize the current literature, and hypothesize on the etiology of this complication.

Penicillium marneffei chylous ascites in acquired immune deficiency syndrome: A case report

Penicillium marneffei (P. marneffei) infection usually occurs with skin, bone marrow, lung or hepatic involvement. However, no cases of P. marneffei infection with chylous ascites have been reported thus far. In this report, we describe the first case of acquired immune deficiency syndrome (AIDS) which has been complicated by a P. marneffei infection causing chylous ascites. We describe the details of the case, with an emphasis on treatment regimen. This patient was treated with amphotericin B for 3 mo, while receiving concomitant therapy with an efavirenz-containing antiretroviral regimen, but cultures in ascitic fluid were persistently positive for P. marneffei. The infection resolved after treatment with high-dose voriconazole (400 mg every 12 h) for 3 mo. P. marneffei should be considered in the differential diagnosis of chylous ascites in human immunodeficiency virus patients. High-dose voriconazole is an effective, well-tolerated and convenient option for the treatment of systemic infections with P. marneffei in AIDS patients on an efavirenz-containing antiretroviral regimen.

Chylous ascites secondary to giant liver hemangioma

Chylous ascites is rare in clinical practice. It is characterized by milky-appearing peritoneal fluid with a triglycerides concentration of >1.25 mmol/l (110 mg/dl). Its pathophysiology is related to a disruption in the normal lymphatic flow. It is more common after trauma (including post surgery), neoplasia or atypical infections such as tuberculosis or filariasis. Other rare medical causes have been reported. The treatment is supportive and focused on correction of the underlying pathology. We report here the first case of chylous ascites caused by giant liver hemangioma and discuss the management of this condition.

Acute chylous peritonitis due to acute pancreatitis

We report a case of acute chylous ascites formation presenting as peritonitis (acute chylous peritonitis) in a patient suffering from acute pancreatitis due to hypertriglyceridemia and alcohol abuse. The development of chylous ascites is usually a chronic process mostly involving malignancy, trauma or surgery, and symptoms arise as a result of progressive abdominal distention. However, when accumulation of “chyle” occurs rapidly, the patient may present with signs of peritonitis. Preoperative diagnosis is difficult since the clinical picture usually suggests hollow organ perforation, appendicitis or visceral ischemia. Less than 100 cases of acute chylous peritonitis have been reported. Pancreatitis is a rare cause of chyloperitoneum and in almost all of the cases chylous ascites is discovered some days (or even weeks) after the onset of symptoms of pancreatitis. This is the second case in the literature where the patient presented with acute chylous peritonitis due to acute pancreatitis, and the presence of chyle within the abdominal cavity was discovered simultaneously with the establishment of the diagnosis of pancreatitis. The patient underwent an exploratory laparotomy for suspected perforated duodenal ulcer, since, due to hypertriglyceridemia, serum amylase values appeared within the normal range. Moreover, abdominal computed tomography imaging was not diagnostic for pancreatitis. Following abdominal lavage and drainage, the patient was successfully treated with total parenteral nutrition and octreotide.

Chylous ascites caused by acute pancreatitis with portal vein thrombosis

Chylous ascites is defined as the accumulation of chyle in the peritoneum due to obstruction or rupture of the peritoneal or retroperitoneal lymphatic glands. Chylous ascites that arises from acute pancreatitis with portal vein thrombosis is very rare. We report here on a case of chylous ascite that was caused by acute pancreatitis with portal vein thrombosis, in which the patient showed an impressive response to conservative therapy with total parenteral nutrition and octerotide. We also review the relevant literature about chylous ascites with particular reference to the management of this rare disease.

Infertility and chylous ascites? A case report

INTRODUCTION

Chylous ascites is defined by an accumulation of chylous fluid in the peritoneal cavity and it clinically appears as a milky fluid in which laboratory examination reveals triglycerides, cholesterol, and sometimes chylomicrons and lymphocytes.

PRESENTATION OF CASE

We report the first case of primary chylous ascites observed during laparoscopy for unexplained secondary infertility.

DISCUSSION

Chylous ascites has never been linked to fertility but bathes all internal reproductive organs surfaces and is considered a communication mean between ovaries.

CONCLUSION

Despite a lack of evidence, the question of peritoneal fluid role remains in infertility.

Anasarca sparing one limb

Upper extremity deep vein thrombosis commonly refers to thrombosis of the axillary and/or subclavian veins. This condition may lead to some serious complications like pulmonary embolism if the diagnosis and treatment are delayed. We introduce here one such case where the diagnosis of this rare condition was difficult because of the atypical clinical manifestation but the chylous ascites provided a valuable clue which led to early diagnosis and treatment of this patient.

Chylous ascites following robotic lymph node dissection on a patient with metastatic cervical carcinoma

Chylous ascites is an uncommon postoperative complication of gynecological surgery. We report a case of chylous ascites following a robotic lymph node dissection for a cervical carcinoma. A 38-year-old woman with IB2 cervical adenocarcinoma with a palpable 3 cm left external iliac lymph node was taken to the operating room for robotic-assisted laparoscopic pelvic and para-aortic lymph node dissection. Patient was discharged on postoperative day 2 after an apparent uncomplicated procedure. The patient was readmitted the hospital on postoperative day 9 with abdominal distention and a CT-scan revealed free fluid in the abdomen and pelvis. A paracentesis demonstrated milky-fluid with an elevated concentration of triglycerides, confirming the diagnosis of chylous ascites. She recovered well with conservative measures. The risk of postoperative chylous ascites following lymph node dissection is still present despite the utilization of new technologies such as the da Vinci robot.

Chylous ascites after nephrectomy without lymphadenectomy for malignant rhabdoid tumor of the kidney: A rare occurrence and literature review

Chylous ascites (CA) is an extremely rare complication of abdominal surgery in children. This report describes a 4-month-old girl with malignant rhabdoid tumor of the kidney (MRTK), who developed CA after left nephrectomy without lymphadenectomy, and who was successfully treated conservatively with enteral therapy. The literature on CA after nephrectomy without lymphadenectomy for MRTK is reviewed herein, and the clinical problems of postoperative CA are discussed.

Acute chylous ascites mimicking acute appendicitis in a patient with pancreatitis

We report a case of acute chylous peritonitis mimicking acute appendicitis in a man with acute on chronic pancreatitis. Pancreatitis, both acute and chronic, causing the development of acute chylous ascites and peritonitis has rarely been reported in the English literature. This is the fourth published case of acute chylous ascites mimicking acute appendicitis in the literature.

Pancreatic portal hypertension complicated with chylous ascites: one-case analysis

Chylous ascites is a rare clinical manifestation characterized by ascitic chylomicrons, ivory white, and its morbidity rate is much lower. Severe acute pancreatitis with pancreatic portal hypertension and chylous ascitesis is more infrequent, and early diagnosis is of great values.

Coughing may lead to spontaneous chylothorax and chylous ascites

Chylous ascites is a rare form of ascites resulting from the accumulation of lymph in the abdominal cavity. It is due to an interruption in the lymphatic system. Surgical management is indicated in cases of recurrence or failure after conservative treatment. We report a case of spontaneous chylous peritonitis after chylothorax, which is a rare clinical event. The primary reason was unclear and the outcome of medical and surgical treatment was successful.

A rare case of pregnancy complicated by mesenteric mass: What does chylous ascites tell us?

Mesenteric fibromatosis is a rare benign nonmetastatic neoplasm that appears as a sporadic lesion or occurs in patients with familial polyposis, while chylous ascites associated with aggressive mesenteric fibromatosis during pregnancy has never been reported thus far. Here we present the case of a 28-year old pregnant woman, in whom an aggressive mesenteric fibromatosis with chylous ascites was detected, involving the jejunum, superior mesenteric artery (SMA) and superior mesenteric vein (SMV) and pancreas. One year after a successful surgical excision, the patient had no signs of recurrence. The authors report the case for its rarity and emphasize on combining clinicopathological, radiological and immunohistochemistry analysis for management of the disease.