The impact of lymphangiograpy on chyle leakage treatment duration after pancreatic surgery

PURPOSE

Chyle leakage (CL) is a common complication in pancreatic surgery. Lymphangiography is a therapeutic option for CL in cases of conservative treatment failure. This study investigated the effect of lymphangiography on the healing time of CL.

METHODS

We retrospectively evaluated 283 patients who underwent pancreatic resection between January 2016 and June 2022. The risk factors for CL and the treatment period were evaluated according to whether or not lymphangiography was performed.

RESULTS

Of the 29 patients (10.2%) that had CL, lymphangiography was performed in 6. Malignant disease, the number of harvested lymph nodes, and drain fluid volume on postoperative day 2 were identified as independent risk factors for CL. Lymphangiography was associated with the cumulative healing rate of CL, and patients who underwent lymphangiography had a significantly shorter treatment period. No lymphangiography-related adverse events were observed.

CONCLUSION

Lymphangiography is a feasible and safe treatment option for CL. The CL treatment period after pancreatic surgery was significantly shorter in patients who underwent lymphangiography than in those who did not. Our results suggest that lymphangiography may contribute to early improvement of persistent CL.

Chylous ascites after associating liver partition and portal vein ligation for stage hepatectomy (ALPPS): overview and case report

Chylous ascites is an uncommon pathology with low incidence following hepato-pancreato-biliary surgery, there are no cases reported in the international literature following the associating liver partition and portal vein ligation for stage hepatectomy (ALPPS) procedure. It is caused by abnormal intraperitoneal accumulation of lymph fluid in the abdominal cavity secondary to obstruction or injury to the chyle cistern or its tributaries. We describe the case of a 49-year-old woman diagnosed with colon cancer and liver metastasis. ALPPS was performed, on a first and second stage, presenting a high drainage output as well as change in the characteristics of the drainage fluid. The diagnosis of chylous ascites was confirmed by finding triglyceride levels in the drainage fluid at 300 mg/dL. Medical treatment was started based on a hyper-protein diet and fat restriction, supplemented with medium-chain triglycerides and somatostatin analog, with fistula resolution. It can be managed with medical treatment.

An Elemental Diet Reduces Chylous Ascites of Patients Undergoing Pancreatoduodenectomy in the Setting of Early Enteral Feeding

OBJECTIVES

The elemental diet (ED) is a formula to support nutritional status without increasing chylous burden. This study evaluates the efficacy of early ED feeding after pancreatoduodenectomy (PD).

MATERIALS AND METHODS

A prospective phase II study of consecutive patients who underwent PD with early ED feeding was conducted. Patient backgrounds, surgical outcomes, and ED feeding tolerability were compared with a historical cohort of 74 PD patients with early enteral feeding of a low residue diet (LRD).

RESULTS

The ED group comprised 104 patients. No patient in the ED group discontinued enteral feeding because of chylous ascites (CAs), whereas 17.6% of the LRD group experienced refractory CAs that disrupted further enteral feeding. The CAs rate was significantly decreased in the ED group compared with the LRD group (3.9% and 48.7%, respectively; P < 0.001). There was no significant difference in the incidence of major complications (ED: 17.3%, LRD: 18.9%; P = 0.844). Postoperative prognostic nutritional index was similar between the 2 groups ( P = 0.764). In multivariate analysis, enteral feeding formula, and sex were independent risk factors for CAs (LRD: P < 0.001, odds ratio, 22.87; female: P = 0.019, odds ratio, 2.78).

CONCLUSIONS

An ED reduces postoperative CAs of patients undergoing PD in the setting of early enteral feeding.

Chylous Ascites Associated with Advanced Pancreatic Cancer That Improved with Appropriate Treatment: A Case Report

Chylous ascites is a rare form of ascites with high triglyceride content arising from the thoracoabdominal lymph nodes in the peritoneal cavity due to various benign or malignant etiologies, including pancreatic cancer. During cancer chemotherapy, the accumulation of ascites can lead to the deterioration of the patient's general condition, making chemotherapy administration difficult, and resulting in a poor prognosis. We encountered a rare case of chylous ascites complicated by advanced pancreatic cancer. The patient presented with a discrepancy between the shrinkage of the pancreatic cancer and the accumulation of ascites. Therefore, we were able to promptly diagnose chylous ascites by performing biochemical tests. The patient was treated with octreotide, reportedly effective in treating chylous ascites, which rapidly improved the chylous ascites and general condition of the patient, allowing the patient to continue chemotherapy for pancreatic cancer. Therefore, physicians should consider the possibility of chylous ascites when clinically unexplained ascites are observed in patients with advanced cancer. The investigation and treatment of chylous ascites should be initiated as soon as possible.

Laparoscopic cholecystectomy: post-operative bile and chyle leaks. A case report

One week after an elective laparoscopic cholecystectomy at an outside hospital, a 56-year-old male presented to the emergency department with right-sided abdominal pain. Computerized tomography (CT) revealed a complex fluid collection in the gallbladder fossa. The patient underwent drain placement and received broad-spectrum intravenous antibiotics. Drain output was suspicious for a chyle leak, which was confirmed by elevated fluid triglyceride levels. Magnetic resonance cholangiopancreatography (MRCP) and hepatobiliary iminodiacetic acid (HIDA) analysis showed evidence of a concurrent bile leak. After starting a low fat, high protein diet and octreotide, a common bile duct sphincterotomy with plastic stent placement was performed. The patient's symptoms and drain output proceeded to improve. The cause of the chyle leak is unclear. However, with consideration of the patient's concurrent bile leak, an injury to the right major lymphatic drainage pathway and adjacent bile duct is suspected.

Chylous ascites following retroperitoneal lymphadenectomy in a patient with recurrent dysgerminoma of ovary: A case report

Chylous ascites is an uncommon condition of accumulation of milky fluid rich in lymph and chylomicrons in the peritoneal cavity. Post-surgical complications following dissection near the base of the mesentery, retroperitoneum, or near the cisterna chyli, malignancies (e.g., pancreatic adenocarcinomas, lymphoma, gastric carcinoma), cirrhosis, and trauma are the prime causes of chylous ascites. Here we report a rare case of chylous ascites following clearance of isolated paraaortic nodal recurrence in a 28-year-old female with dysgerminoma of ovary. The patient developed chylous ascites on the fifth day following surgery, which was confirmed by an increased drain fluid triglyceride level. She was managed conservatively with dietary modification including a high-protein and carbohydrate but low-fat-based diet mainly containing medium-chain fatty acids. Subsequently, she recovered from chylous ascites on the sixteenth day, completed second line chemotherapy, and is now doing well.

Chyloperitoneum and Chylothorax Following Bariatric Surgery: a Systematic Review

Chyloperitoneum and chylothorax (ChP/ChT) are rare complications after bariatric surgery. This systematic review aims to evaluate the incidence, cause, treatment, and outcome of ChP and ChT after bariatric surgery. This review investigates published English language scientific literature systematically in an attempt to answer these questions. Our literature search revealed 66 studies, of which 23 were included. There were a total of 40 patients (38, ChP; 2, ChT). Eighteen of 40 (43.9%) patients were treated laparoscopically, and one patient (2.44%) underwent thoracoscopy and ligation of the thoracic duct. Both ChP and ChT are rare complications after bariatric surgery.

Significance of the dissection of common hepatic arterial lymph nodes in patients with oesophageal carcinoma: a multicentre retrospective study

OBJECTIVES

To explore the significance of intraoperative common hepatic arterial lymph node dissection in patients with ooesophageal squamous carcinoma (ESCC) without coeliac trunk lymph node metastasis indicated by abdominal enhanced CT.

METHODS

Patients aged 18-75 years who underwent oesophagectomy in three medical centres from June 2012 to June 2015, for whom R0 resection was completed and lymph node metastasis in the abdominal trunk was not identified before the operation were retrospectively analysed. The effects of the application value of common hepatic arterial lymph node dissection on survival were evaluated in patients with ESCC without coeliac trunk lymph node metastasis indicated by preoperative CT. According to the eighth version ofAmerican Joint Committee on Cancer (AJCC)/Union for International Cancer Control (UICC) staging, we selected patients with a Pathological Tumor Node Metastasis (pTNM) stage ranging from IA to IVA for analysis.

RESULTS

Among the 816 qualified patients, 577 did not have coeliac trunk lymph node metastasis based on preoperative abdominal enhanced CT, and common hepatic arterial lymph node dissection was performed during the operation (observation group). Two hundred and thirty-nine preoperative CT examinations indicated no coeliac trunk lymph node metastasis, and common hepatic arterial lymph node dissection was not performed during the operation (control group). A multifactor Cox proportional hazards model showed no risk factors for overall survival (OS) (adjusted HR (HRadj)=0.91; p=0.404) or disease-free survival (DFS) (HRadj=0.86; p=0.179), regardless of whether common hepatic arterial lymph node dissection was performed. For patients with positive left gastric arterial lymph node metastasis, a multifactor Cox proportional hazards model indicated that common hepatic arterial lymph node dissection was a risk factor for OS (HRadj=0.63; p=0.035) and DFS (HRadj=0.58; p=0.026).

CONCLUSIONS

For patients with ESCC without celiac trunk metastasis indicated by abdominal enhanced CT, common hepatic arterial lymph node dissection conferred no survival benefits. However, for patients with left gastric arterial lymph node metastasis, common hepatic arterial lymph node dissection was beneficial.

Incidence and risk factors for Chyle leak after pancreatic surgery for cancer: A comprehensive systematic review

BACKGROUND

Chyle leak (CL) is a clinically relevant complication after pancreatectomy. Its incidence and the associated risk factors are ill defined, and various treatments options have been described. There is no consensus, however, regarding optimal management. The present study aims to systematically review the literature on CL after pancreatectomy.

METHODS

A systematic review from PubMed, Scopus and Embase database was performed. Studies using a clear definition for CL and published from January 2000 to January 2021 were included. The PRISMA guidelines were followed during all stages of this systematic review. The MINORS score was used to assess methodological quality.

RESULTS

Literature search found 361 reports, 99 of which were duplicates. The titles and abstracts of 262 articles were finally screened. The references from the remaining 181 articles were manually assessed. After the exclusions, 43 articles were thoroughly assessed. A total of 23 articles were ultimately included for this review. The number of patients varied from 54 to 3532. Incidence of post pancreatectomy CL varied from 1.3% to 22.1%. Main risk factors were the extent of the surgery and early oral or enteral feeding. CL dried up spontaneously or after conservative management within 14 days in 53% to 100% of the cases.

CONCLUSIONS

The extent of surgery is the most common predictor of risk of CL. Conservative treatment has been shown to be effective in most cases and can be considered the treatment of choice. We propose a management algorithm based on the current available evidence.

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

AIM

This 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.

METHOD

Consecutive 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.

RESULTS

Among 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.

CONCLUSION

The 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.

Systematic review of the incidence and risk factors for chyle leak after pancreatic surgery

BACKGROUND

The incidence of and risk factors for chyle leak, as defined by the 2017 International Study Group on Pancreatic Surgery, remain unknown.

METHODS

MEDLINE, EMBASE, and Scopus were systematically searched for studies of patients undergoing pancreatectomy that reported chyle leak according to the 2017 International Study Group on Pancreatic Surgery definition. The primary outcomes were the incidence of overall and clinically relevant chyle leak. A random-effects pairwise meta-analysis was used to calculate the incidence of chyle leak.

RESULTS

Thirty-five studies including 7,083 patients were included in the meta-analysis. The weighted incidence of overall chyle leak was 6.8% (95% confidence interval 5.6-8.2), and clinically relevant chyle leak was 5.5% (95% confidence interval 3.8-7.7). Pancreaticoduodenectomy, total pancreatectomy, and distal pancreatectomy were associated with a CL incidence of 7.3%, 4.3%, and 5.8%, respectively. Fourteen individual risk factors for chyle leak were identified from included studies. Younger age, low prognostic nutritional index, para-aortic node manipulation, lymphatic involvement, and post-pancreatectomy pancreatitis were significantly associated with chyle leak, all from individual studies.

CONCLUSION

The incidence of overall chyle leak and clinically relevant chyle leak after pancreatic surgery, as defined by the 2017 International Study Group on Pancreatic Surgery, is 6.8% and 5.5%, respectively. Several risk factors for chyle leak were identified in the present review; however, larger high-quality studies are needed to more accurately define these risks.

Hepatic lymphorrhea following pancreaticoduodenectomy: Preliminary diagnosis and treatment experience from case series of four patients

Introduction

Hepatic lymphorrhea (HL) is an uncommon but potentially life-threatening type of postoperative lymphatic leakage, especially following pancreaticoduodenectomy.

Case presentation

We herein report a case series of four patients with HL following pancreaticoduodenectomy that presented to the department with a severe clinical picture with the discovery in imaging and intraperitoneal fluid's tests. All our patients presented with a condition of Hepatic lymphorrhea secondary to pancreaticoduodenectomy, which were treated successfully with percutaneous hepatic lymphangiography (HLG).

Discussion

Hepatic lymphorrhea is an uncommon but potentially life-threatening complication following pancreaticoduodenectomy. Periportal lymphatic vessels, which was often isolated and dissected especially with extended lymphadenectomy, is potentially damaged and caused resistant chylous leakage. Newly techniques are updated and applied in diagnosis and treatment for this difficult-to-treat complication, one of them is percutaneous Hepatic Lymphangiography (HLG).

Conclusion

HLG with percutaneous access could be effective to identify and terminate the chylous fistula from periportal lymphatic vessels after pancreaticoduodenectomy.

•

Hepatic lymphorrhea is a rare, life-threatening complication of pancreaticoduodenectomy.

•

Periportal lymphatic vessels was a potential location of lymphatic fistula and leakage.

•

This complication can be diagnosed with imaging and intraperitoneal fluid's tests.

•

Hepatic lymphangiography is a minor-invasive therapy to close the lymphatic fistula.

Chylous retroperitoneum following 720 degree anteroposterior-combined corrective surgery for adult spinal deformity with split vertebral fracture subluxation: a case report

STUDY DESIGN

Clinical case report.

PURPOSE

To report the rare case with post-operative chylous retroperitoneum after corrective surgery for adult spinal deformity.

METHODS

We present a case of a 73-year-old woman with Parkinson's disease. She sustained a severe split fracture subluxation of the L3 vertebra with AO Spine Thoracolumbar classification type CN2M2, resulting in severe kyphoscoliosis in global alignment. She underwent a two-stage 720-degree anteroposterior-combined corrective surgery with anterior vertebral column resection of L3 and posterior fusion from T4 to the pelvis. On post-operative day 1, milky fluid in the drainage tube was noted, which was diagnosed as post-operative chylous retroperitoneum.

RESULTS

Oral intake was discontinued immediately and peripheral parenteral nutrition was started. A low-fat, high-protein diet was started on post-operative day 4, and drainage was removed on day 6. A low-fat diet was continued until 3 months post-operatively, with dietary counselling by a nutritionist. The chylous retroperitoneum resolved without recurrence at the final follow-up evaluation at 3 years.

CONCLUSION

Surgeons should recognize this rare complication, which might be induced by direct damage to the lymphatic flow during an operative maneuver anterior to the lumbar vertebral body and indirect damage due to shearing force during correction of a subluxated vertebra, especially in cases with a severe deformity.

Ligation and Fibrin Glue Spraying for Intractable Chylous Ascites after Radical Gastrectomy for Gastric Cancer: Case Report and Literature Review

Chylous ascites associated with radical resection of gastric cancer is a serious clinical condition. Lymph node dissection is indispensable during gastrectomy for gastric cancer. However, postoperative chylous ascites prolongs the hospital stay and re-operation. There are few reports on this subject. Most cases of chylous ascites resolve without treatment, but the condition can result in substantial morbidity. The definition of chylous ascites is ambiguous and varies in the English literature. In this report, we discuss a case of chylous ascites in a 68-year-old man who underwent distal gastrectomy for early gastric cancer at our hospital. He was admitted 8 months after surgery with a main complaint of abdominal swelling. Abdominal puncture helped to diagnose chylous ascites with marked elevation of triglyceride level. The patient received a hypercaloric infusion through a central line, and octreotide acetate, but did not improve. After assessment of lymph outflow by lymph scintigraphy, surgical ligation of the lymph vessels was performed through laparotomy. The volume of milky-white ascites in the abdominal cavity was 3,000 mL. Macroscopically, the fluid was confirmed as flowing from behind the common hepatic artery. Thus, ligation was performed. Chylous ascites has not recurred at 12 months after the re-operation. In summary, a case of chylous ascites after radical gastrectomy for gastric cancer was successfully treated by surgery. We review and discuss the relevant literature.

Daily Triglyceride Output Volume as an Early Predictor for Chyle Leak Following Pancreaticoduodenectomy

BACKGROUND/AIM

Useful prophylaxes of chyle leak (CL) after pancreatic surgery have not been established. The aim of the study was to identify an early clinical predictor for CL.

PATIENTS AND METHODS

Fifty-five patients who underwent subtotal stomach preserved pancreaticoduodenectomy (SSPPD) were included. Clinical factors associated with postoperative CL were evaluated.

RESULTS

Eleven patients (20%) developed a CL after SSPPD. Shorter operative time, absent pancreatic fistula, and triglyceride output volume at postoperative day (POD) two were independent risk factors for CL. The receiver operating characteristics curve of the daily triglyceride output volume at POD two indicated a cut-off point of 177 mg (AUC=0.782; p=0.004; 95% CI=0.639-0.925). CL was significantly associated with prolonged postoperative hospital stay in patients who did not develop a pancreatic fistula (p=0.003).

CONCLUSION

Daily triglyceride output volume of >177 mg at POD two may be a predictor of CL following pancreaticoduodenectomy.

Drain output volume after pancreaticoduodenectomy is a useful warning sign for postoperative complications

Introduction

The drain output volume (DOV) after pancreaticoduodenectomy (PD) is an easily assessable indicator in clinical settings. We explored the utility of the DOV as a possible warning sign of complications after PD.

Methods

A total of 404 patients undergoing PD were considered for inclusion. The predictability of the DOV for overall morbidity, major complications, intraabdominal infection (IAI), clinically relevant (CR) postoperative pancreatic fistula (POPF), CR delayed gastric emptying (DGE), CR chyle leak (CL), and CR post-pancreatectomy hemorrhaging (PPH) was evaluated.

Results

One hundred (24.8%) patients developed major complications, and 131 (32.4%) developed IAI. Regarding CR post-pancreatectomy complications, 75 (18.6%) patients developed CR-POPF, 23 (5.7%) developed CR-DGE, 20 (5.0%) developed CR-CL, and 28 (6.9%) developed CR-PPH. The median DOV on postoperative day (POD) 1 and POD 3 was 266 and 234.5 ml, respectively. A low DOV on POD 1 was an independent predictor of CR-POPF, and a high DOV on POD 3 was an independent predictor of CR-CL. A receiver operating characteristics (ROC) analysis revealed that the DOV on POD 1 had a negative predictive value (area under the curve [AUC] 0.655, sensitivity 65.0%, specificity 65.3%, 95% confidence interval [CI]: 0.587–0.724), with a calculated optimal cut-off value of 227 ml. An ROC analysis also revealed that the DOV on POD 3 had a positive predictive value (AUC 0.753, sensitivity 70.1%, specificity 75.0%, 95% CI: 0.651–0.856), with a calculated optimal cut-off value of 332 ml.

Conclusion

A low DOV on POD 1 might be a postoperative warning sign for CR-POPF, similar to high drain amylase (DA) on POD 1, high DA on POD 3, and high CRP on POD 3. When the DOV on POD 1 after PD was low, surgeons should evaluate the reasons of a low DOV. A high DOV on POD 3 was a postoperative warning sign CR-CL, and might require an appropriate management of protein loss.

Successful minimal invasive treatment of chylous ascites following pancreaticoduodenectomy: A case report and review of literature

Introduction

Chylous ascites is an uncommon but potentially life-threatening type of postoperative lymphatic leakage, especially following pancreaticoduodenectomy.

Case presentation

A 59-year-old man underwent pancreaticoduodenectomy (PD) with extended lymphadenectomy and segmental Superior Mesenteric Vein (SMV) resection for SMV-involved pancreatic ductal adenocarcinoma (PDAC). After 20th postoperative day, patient had a drain output with a milky appearance, and with a triglyceride level was 1.6 mmol/L, and the daily output volume was up to 1500 mL per day. She has been performed Conventional Lymphangiography (CLAG) to identify the broken lymphatic vessels as well as close the leakage. Following two consecutive lymphangiography, the source of chylous leakage was identified from hilar lymphatic system, and injection of Aetoxisclerol 2% into lymphatic vessels to close the leakage was performed. Partial parenteral nutrition with limited fat components or medium-chain triglyceride (MCT) was administered, and the amount of ascites decreased particularly. The drain was removed in 20th day after the second CLAG. He had no symptoms of abdominal distention after drain removal and had been discharged after 37 postoperative days (PODs).

Discussion

Chylous ascites is an uncommon but potentially life-threatening complication following pancreaticoduodenectomy. Portal lymphatic plexus, which was often isolated and dissected especially with extended lymphadenectomy, is potentially damaged and caused resistant chylous leakage. Newly techniques are updated and applied in diagnosis and treatment for this difficult-to-treat complication, one of them is percutaneous transhepatic Conventional Lymphangiography (CLAG).

Conclusion

CLAG with percutaneous transhepatic access could be effective to identify and terminate the chylous fistula from portal lymphatic plexus after pancreaticoduodenectomy.

•

Chylous ascites is a potentially life-threatening type of lymphatic leakage, following pancreaticoduodenectomy.

•

Portal lymphatic plexus was a potential location of lymphatic fistula due to the regularity of isolation and dissection in pancreaticoduodenectomy with extended lymphadenectomy.

•

Conventional Lymphangiography (CLAG) is an invasion to identify the broken lymphatic vessels and close the leakage.

•

Percutaneous transhepatic CLAG is a technique to puncture the portal lymphatic vessels, which could not be approached with other methods.

Postoperative chyle leak after pancreatic surgery - Is treatment effective?

PURPOSE

With increasing soft tissue clearance in pancreatic cancer surgery, postoperative chyle leak (CL) has become a more commonly observed complication. Recently, a new consensus definition was established by the International study group of pancreatic surgery (ISGPS). The aim of the present analysis was to evaluate risk factors and treatment options of patients with CL after pancreatic surgery.

METHODS

Two hundred and twenty-eight patients with serous or chylous drainage after pancreatic surgery were included in this analysis of a prospectively collected database between 01/2014 and 12/2016. Risk factors for CL and treatment options were compared. A subgroup analysis on those patients, who had drain removal despite of persistent CL with respect to the need of subsequent percutaneous drainage or reoperation within three months postoperatively, was performed.

RESULTS

Sixty patients with CL were identified. Of those, 41 patients were treated with medium-chain triglyceride-diet, with a median duration of therapy of 12 days. In patients with CL, the type of treatment had no effect on time to drain removal (P=0.29) and morbidity (P=0.15). Furthermore, morbidity was not increased in patients who had their drains removed despite persistent CL (P=0.84). None of the latter patients had percutaneous drainage or reoperation for CL after removal of the surgical drains.

CONCLUSIONS

Dietary treatment may not be very effective in treating CL. Further research is warranted to explore the effect and necessity of CL treatment.

Chyle leak following pancreatico-duodenectomy: a tertiary hepatopancreaticobiliary unit's experience and a proposed management algorithm

BACKGROUND

Chyle leak (CL) is an uncommon complication of pancreatico-duodenectomy (PD). Its incidence, risk factors, and effect on prognosis are not well described and optimum management remains debated. This study aims to calculate incidence of CL following PD and identify risk factors. Following a literature review, we have proposed a management algorithm.

METHODS

This is a retrospective review of all patients who underwent PD between January 2006 and April 2020 at a tertiary hepatopancreaticobiliary unit in the UK. The following data were obtained: age, gender, American Society of Anesthesiologists grade, body mass index, co-morbidities, duration of surgery, tumour histology, length of stay and mortality.

RESULTS

A total of 560 patients were included. Seventeen developed CL (3.04%). Median age was 64 years (range 50-81). Sixteen (94.1%) patients still had their surgical drain in at the time of CL diagnosis. One (5.9%) did not and had free intra-abdominal fluid on computed tomography; a diagnosis was made after an ultrasound-guided drain had been inserted. CL patients were more likely to have higher body mass index (mean 30.5 kg/m² (range 17-43) versus 26.7 kg/m² (22-38)) (P = 0.02) and longer duration of operation (mean 6.2 h (range 4.3-9.0) versus 5.6 (3.0-11.0)) (P = 0.03). All cases of CL resolved without operative intervention. CL did not affect length of stay (median 10 days (range 4-41) versus 11 (4-34)).

CONCLUSIONS

In our series, 3.04% of patients who underwent PD developed CL. No patients required a return to theatre, and none had CL recurrence.

Chylous ascites following elective abdominal aortic aneurysm repair

Postoperative chylous ascites is a rare complication of abdominal surgery. Chyle depletion results in nutritional, immunologic and metabolic deficiencies, making it a serious and potentially life-threatening condition for which prompt diagnosis and management is imperative. A 72-year-old male was referred for open repair of a 62 cm juxtarenal abdominal aortic aneurysm (AAA). Following resumption of diet, he developed abdominal distention. Therapeutic paracenteses confirmed chylous ascites. Failed conservative management and lymphatic embolization lead to surgical sealance of lymphatic leak using glue. Postoperatively, a full diet was tolerated with no further ascites. Paracentesis is the diagnostic modality of choice in evaluating patients with ascites. Management is challenging and should be multifaceted and tailored to individual patient needs. Cornerstones of therapy include correction of the underlying etiology and conservative measures. When conservative measures fail, other interventions can be considered, such as somatostatin analogs, surgical ligation or glue embolization.

Association Between Neoadjuvant Chemoradiotherapy and Intractable Serous Ascites After Pancreaticoduodenectomy for Pancreatic Cancer

BACKGROUND

Intractable serous (not chylous) ascites (IA) that infrequently develops early following pancreaticoduodenectomy (PD) for pancreatic cancer is a life-threatening problem. The relationship between neoadjuvant chemoradiotherapy (NACRT) for pancreatic cancer and the incidence of IA following PD has not been evaluated. This study aims to identify the risk factors associated with IA that develops early after PD for pancreatic cancer.

METHODS

We retrospectively identified 94 patients who underwent PD for pancreatic cancer at the Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, Osaka, Japan, from April 2012 to March 2020. Data on 29 parameters were obtained from medical records. Univariate and multivariate analyses were conducted to identify independent risk factors. Levels of serum albumin were compared before and after NACRT to analyze its effect. Survival analysis was also conducted.

RESULTS

Of the 92 patients included in this study, 8 (8.70%) were categorized into the IA group. Multivariate analysis identified NACRT [odds ratio (OR) 27, 95% confidence interval (CI) 1.87-394, p = 0.016)] and hypoalbuminemia (≤ 1.6 g/dl) just after the operation (OR 50, 95% CI 1.68-1516, p = 0.024) as risk factors. The level of serum albumin was significantly decreased following NACRT. The IA group had poorer prognosis than the control group.

CONCLUSIONS

IA is a serious problem that aggravates patient's prognosis. Postoperative lymphatic leak might be a trigger of IA. NACRT was a major risk factor, followed by hypoalbuminemia caused by various reasons. These factors may act synergistically and cause IA.

Early Versus Late Oral Refeeding After Pancreaticoduodenectomy for Malignancy: a Comparative Belgian-French Study in Two Tertiary Centers

BACKGROUND

In the era of fast-track surgery, because pancreaticoduodenectomy (PD) carries a significant morbidity, surgeons hesitate to begin early oral feeding and achieve early discharge. We compared the outcome of two different approaches to the postoperative management of PD in two tertiary centers.

METHODS

Of patients having undergone PD for malignancy from 2008 to 2017, 100 patients who received early postoperative oral feeding (group A) were compared to 100 patients from another center who received early enteral feeding and a delayed oral diet (group B). Surgical indication and approach and type of pancreatic anastomosis were similar between both groups. Postoperative outcomes were retrospectively reviewed.

RESULTS

Patient characteristics were similar between both groups, except significantly more neoadjuvant treatment in group A (A = 20% vs. B = 9%, p < 0.01). Mortality rates were 3% and 4% in groups A and B, respectively (p = 0.71). The rate of severe postoperative morbidity was significantly lower in group A (13% vs. 26%, p = 0.02), resulting in a lower reoperation rate (p < 0.01). Delayed gastric emptying and clinically relevant pancreatic fistula were similar between both groups but chyle leaks were more frequent in group A (10% vs. 3%, p = 0.04). The median hospital stay was shorter in group A (16 vs. 20 days, p < 0.01).

CONCLUSION

In the present study, early postoperative oral feeding after PD was associated with a shorter hospital stay and did not increase severe postoperative morbidity or the rate of pancreatic fistula. However, it resulted in more chyle leaks and did not prevent delayed gastric emptying.

Successful management of chylous ascites after pancreatoduodenectomy using etilefrine: a case report

An 84-year-old woman underwent subtotal stomach pancreatoduodenectomy (PD) for distal cholangiocarcinoma. Over 1000 ml of serous ascites, which appeared milky after starting a high-protein, low-fat, middle-chain triglyceride diet, was discharged from the inserted drain. On postoperative day (POD) 13, she underwent right hemicolectomy for transverse colonic volvulus, which occurred on POD 9 and was refractory to conservative therapies. Following second surgery, the chylous ascites (CA) amount continued to increase. Octreotide, albumin and diuretics were administered, but the amount of ascites did not decrease. Etilefrine was administered on POD 19; the ascites amount gradually decreased. The drain was removed 3 days after etilefrine administration. She had no symptoms of abdominal distention after drain removal. Etilefrine’s effectiveness for chylothorax after esophagectomy and CA after distal pancreatectomy has been reported. We present a case of CA successfully treated by etilefrine following PD. Our case highlights etilefrine’s usefulness for CA following PD.

Chyle leakage after robotic and open pancreaticoduodenectomy

BACKGROUND

Chyle leakage is a well-known but poorly characterized complication after pancreaticoduodenectomy (PD). No study examined the chyle leakage after robotic PD (RPD).

METHODS

Data regarding chyle leakage were prospectively collected and analyzed from patients undergoing RPD or open PD (OPD).

RESULTS

The study included 118 RPD and 165 OPD. Overall chyle leakage rate was 12.0%, with 13.6% for RPD and 10.9% for OPD. Chyle leakage was eventually resolved in all patients through conservative treatment. The drainage volumes were significantly higher in chyle leakage group from postoperative days (PODs) 1-7, with a median of 240 mL on POD 1 and POD 7, as compared to 160 mL on POD 1 and 70 mL on POD 7 for those without chyle leakage. The number of lymph nodes involved and resected and pancreatic head adenocarcinoma affected the risk of developing chyle leakage, whereas the surgical approach used (RPD or OPD) did not.

CONCLUSIONS

Chyle leakage after PD is not rare, and it can eventually be resolved through conservative treatment. The extent and radicality of the surgery probably have a significant effect on the risk of developing chyle leakage, but the surgical approach used does not.

Postoperative Lymphorrhagia- a Possible Complication Following Cephalic Duodenopancreatectomy

Surgery associated with lymphadenectomy may sometimes result in a lymphorrhagia, which usually resolves spontaneously within a few days, sometimes becoming a refractory complication to the treatment. In the case of large flows, particular attention should be paid to hydro-electrolytic and protein losses. We present the case of a patient with persistent lymphorrhagia after a cephalic duodenopancreatectomy for a pancreatic head tumor. From the 5th postoperative day, the patient had a milky-like secretion on the subhepatic drainage tube. The discharge rate was variable, between 500 and 1500 ml per day, requiring parenteral administration of amino acids, plasma and electrolyte solutions. The postoperative progression was slowly favorable, with the patient discharge on the 25th day following surgery. There are several treatment options for a lymphorrhagia following an extended lymphadenectomy, from intensive parenteral therapy to peritoneal-venous shunt or ligation of the lymphatic vessel responsible for the production of lymphorrhagia. In this case the conservative treatment had a favorable result.

Relationship Between Early Oral Intake Post Pancreaticoduodenectomy and Chyle Leakage: A Retrospective Cohort Study

BACKGROUND

Early oral intake is strongly recommended according to the enhanced recovery after surgery (ERAS) guidelines because it can reduce complications and improve recovery. However, early oral intake has been indicated to be associated with chyle leakage (CL) after pancreatic surgery, which may lead to worsening of existing malnutrition and impeded recovery. This study investigated the relationship between early oral intake and CL and identified risk factors for CL to reduce its occurrence and promote recovery after pancreaticoduodenectomy.

MATERIALS AND METHODS

All patients who underwent pancreaticoduodenectomy between June 2014 and June 2018 were identified retrospectively. Patients were divided into the early-oral-intake and control groups according to whether they had early oral intake according to ERAS protocols. CL and other clinicopathological characteristics were recorded. Univariable and multivariable analyses assessed CL risk factors.

RESULTS

Early oral intake improved recovery, leading to a shorter postoperative hospital stay for the early-oral-intake group in comparison to that of the control group [13.6 (range, 12-68) vs. 17.8 (range, 14-83) days; p = 0.047] without increasing the incidence of CL and other complications. CL was diagnosed significantly earlier in the early-oral-intake group than in the control group [4.6 (range 3-5) vs. 6.7 (range 3-9) days; p = 0.001]. Early oral intake did not increase the grade severity (p = 0.845) or the costs (p = 0.241) or prolong postoperative hospital stays (p = 0.611). A primary diagnosis of malignancy, para-aortic lymph node dissection, lymphatic invasion, lymph node metastases, the number of harvested nodes, and the number of positive nodes were significantly associated with CL (p < 0.05), whereas early oral intake was not (p = 0.525). Multivariate analyses demonstrated that para-aortic lymph node dissection (p = 0.039) and the number of harvested nodes (p = 0.001) were independent risk variables.

CONCLUSION

This study provides significant evidence that early oral intake after pancreaticoduodenectomy is not associated with CL. The identification of the independent risk factors for CL can help prevent it.

Combined Chylothorax and Chylous Ascites Complicating Liver Transplantation: A Report of a Case and Review of the Literature

Chyle leaks may occur as a result of surgical intervention. Chyloperitoneum, or chylous ascites after liver transplantation, is rare and the development of chylothorax after abdominal surgery is even more rare. With increasingly aggressive surgical resections, particularly in the retroperitoneum, the incidence of chyle leaks is expected to increase in the future. Here we present a unique case of a combined chylothorax and chyloperitoneum following liver transplantation successfully managed conservatively. Risk factors for chylous ascites include para-aortic manipulation, extensive retroperitoneal dissection, use of a Ligasure device, and early enteral feeding as well as early enteral feeding. The clinical presentation is typically insidious and may include painless abdominal distension. Diagnosis can be made by noting characteristic milky white drainage which on laboratory examination has a total fluid triglyceride level >110 mg/dl, an ascites/serum triglyceride ratio of >1 and a leukocyte count in fluid >1000/uL with a lymphocyte predominance. Chyle leaks may lead to significant morbidity and mortality. Numerous management options exist, with conservative nonoperative measurements leading to the most consistent and successful outcomes. This includes a step-up approach beginning with dietary modifications to a low-fat or medium chain triglyceride diet followed by nil per os with addition of total parenteral nutrition and somatostatin analogues such as octreotide. Rarely do patients require more invasive treatment. Early recognition and appropriate management are imperative to mitigate this complication.

Complications of Retroperitoneal Lymph Node Dissection

Retroperitoneal lymph node dissection is an integral part of the management of testicular cancer. Surgical approach and outcomes have improved over the past decades. Several factors influence the complexity of the operation, including numerous patient characteristics and disease-related characteristics. An important consideration lies in the fact that this is largely a vascular operation, and techniques of vascular control should be comfortable for the urologic surgeon performing the procedure. This article discusses the known surgical complications related to this operation and their relative incidence reported throughout the literature.

Management of chylous ascites following pancreaticobiliary surgery

Background

Chyle leak is an uncommon form of ascites occurring due to the accumulation of lipid‐rich lymph into the peritoneal cavity. Traumatic injury to the lymphatic system due to pancreaticobiliary surgery can lead to this phenomenon.

Method

We retrospectively evaluated the data of 159 patients of pancreticobiliary surgery from January 2012 to December 2016. Five patients (5/137, 3.6%) sustained a chylous leak following pancreaticoduodenectomy and one patient (1/22, 4.5%) sustained a chylous leak following Roux‐en‐Y hepaticojejunostomy for postcholecystectomy biliary stricture.

Results

Average daily output was 441 mL (range: 150–800 mL/day), and total duration of output was 16.5 days (range: 4–35 days). Mean hospital stay increased to 19.1 days (range: 10–40 days). All the patients were successfully managed conservatively with a combination of customized enteral feeds, supplemental parenteral nutrition, and octreotide. One patient required additional percutaneous drainage.

Conclusion

Chyle leak can be successfully treated with conservative management but at the cost of increased hospital stay.

Chyle leak after pancreatic surgery: validation of the International Study Group of Pancreatic Surgery classification

BACKGROUND

Chyle leak is an uncommon complication after pancreatic surgery. The chyle leak incidence, definition, diagnosis, and treatment had been reported heterogeneously so far. Recently a consensus definition and grading system was published by the International Study Group for Pancreatic Surgery. This study aims to evaluate the differences in the clinical and economic burden of chyle leak applying the new definition.

METHODS

All data from patients who underwent pancreatic surgery for any disease from January 2014 to December 2016 were retrieved from the institutional prospective database. The 2017 International Study Group for Pancreatic Surgery definition and classification were applied. The classification was validated analyzing the differences in major complications, length of stay, and hospitalization costs.

RESULTS

A total of 945 patients was the final population. A chyle leak was reported in 43 patients (4.5%). Grade A chyle leak occurred in 10 patients (23.3%), Grade B chyle leak in 31 patients (72.1%), and Grade C chyle leak in 2 patients (4.6%). Chyle leak occurred as unique postoperative complication in 29 cases (67.4%). The economic analysis showed that the average costs of the 3 grades were 2,806, 7,150 and 15,684 euros respectively (P < .001). Furthermore, the length of stay, the rates of septic events, and major complications were significantly different among the 3 grades (P = .008, P = .004, and P < .001, respectively). Of note, we did not find any intraoperative factor associated with chyle leak.

CONCLUSION

The present study confirms the validity of the International Study Group for Pancreatic Surgery classification of chyle leak. The 3 grades of chyle leak proposed identify reliably clinical and economical differences among the chyle leak cases.

Rare, Uncommon, and Unusual Complications After Pancreaticoduodenal Resection

Complications after pancreaticoduodenal resection occur in at least 30% of patients. Most are a direct result of an intraoperative event, dissection, or anastomoses which account for the most serious morbidities, sepsis, pseudoaneurysms, and hemorrhage. Rarely, complications are due to the systemic impact of the procedure even if the procedure itself was unremarkable. Rare systemic complications after PDR (Transfusion transmitted Babesiosis, pituitary apoplexy, and TRALI) and a number of uncommon and unusual other complications are discussed. Pancreaticoduodenal resection is a significant operation with serious consequences. Decisions on selection of candidates and safe operations should be thoughtful and always in surgeons' minds.

Periportal lymphatic system on post-hepatobiliary phase Gd-EOB-DTPA-enhanced MR imaging in normal subjects and patients with chronic hepatitis C

PURPOSE

We sought to evaluate visualization of periportal lymphatics and lymph nodes (lymphatic system) on Gd-EOB-DTPA-enhanced magnetic resonance (MR) images using a fat-suppressed T2-weighted sequence with 3-dimensional (3D) volume isotropic turbo spin echo acquisition (VISTA) at 3.0 T in normal subjects and patients with chronic hepatitis C.

METHODS

MR imaging was performed in 254 subjects between June 2013 and May 2016. After applying inclusion and exclusion criteria, the final population was 31 normal subjects and 34 patients with chronic hepatitis C. Images were acquired after the hepatobiliary phase following intravenous administration of Gd-EOB-DTPA, which causes signal loss in the bile ducts, to facilitate the visualization of the periportal lymphatic system. Two radiologists assessed the visualization of the periportal lymphatic system in 31 normal subjects. The axial dimensions of the main periportal lymphatic system in normal subjects were measured and compared with those of 34 patients with chronic hepatitis C using the Mann-Whitney U-test, and their correlation with a hepatic fibrosis marker, the Fibrosis-4 (FIB-4), was assessed using Spearman's rank correlation test.

RESULTS

The periportal lymphatic system was detected as high signal intensity areas surrounding the portal vein up to the third branches by each reader in all normal subjects. The axial dimensions of the main periportal lymphatic system in patients with chronic hepatitis C were significantly larger than those in normal subjects (p < 0.0001), and showed a significantly positive correlation with the FIB-4 score (ρ = 0.73, p < 0.001).

CONCLUSIONS

Fat-suppressed T2-weighted MR imaging with 3D-VISTA acquired after the hepatobiliary phase on Gd-EOB-DTPA-enhanced imaging may be a useful noninvasive method for evaluating the periportal lymphatic system and the degree of hepatic fibrosis.

Low-dose radiation therapy for massive chylous leakage after subtotal gastrectomy

Massive chylous leakage is a rare postoperative complication that can prolong hospital stay and cause secondary morbidities. Conservative management strategies are the treatment of choice; however, radiation therapy (RT) can be used as an alternative for cases that are refractory to conservative treatment. Herein, we report a 69-year-old female patient who suffered from massive chylous leakage after subtotal gastrectomy. Due to persistent massive chylous leakage, she was scheduled to undergo low-dose RT. Radiation was delivered with a daily dose of 1 Gy, using an anterior-posterior and posterior-anterior beam arrangement. The clinical target volume encompassed the entire lymph node area of the D2 dissection. RT was completed at the total dose of 8 Gy because the amount of chylous leakage declined rapidly. Percutaneous drainage tube was removed after 3 days of RT. The patient did not complain of any symptoms related to massive chylous leakage 2 years after the completion of RT.

Chylous ascites after resection of giant adrenocortical carcinoma

Postoperative chylous ascites (PCA) is a rare clinical state that occurs during abdominal surgery. Despite its rarity, the need to diagnose and treat PCA is increasing in importance with the increased number of wide resections and lymph node dissections being performed and the serious consequences of treatment. Here we describe the PCA complications we observed after resection for treating a case of giant adrenocortical carcinoma and we have the brief review of the PCA complication.

Incidence, risk factors and clinical implications of chyle leak after pancreatic surgery

Background

Chyle leak is a well known but poorly characterized complication after pancreatic surgery. Available data on incidence, risk factors and clinical significance of chyle leak are highly heterogeneous.

Methods

For this cohort study all patients who underwent pancreatic surgery between January 2008 and December 2012 were identified from a prospective database. Chyle leak was defined as any drainage output with triglyceride content of 110 mg/dl or more. Risk factors for chyle leak were assessed by univariable and multivariable analyses. The clinical relevance of chyle leak was evaluated using hospital stay and resolution by 14 days for short-term outcome and overall survival for long-term outcome.

Results

Chyle leak developed in 346 (10·4 per cent) of 3324 patients. Pre-existing diabetes, resection for malignancy, distal pancreatectomy, duration of surgery 180 min or longer, and concomitant pancreatic fistula or abscess were independent risk factors for chyle leak. Both isolated chyle leak and coincidental chyle leak (with other intra-abdominal complications) were associated with prolonged hospital stay. Some 178 (87·7 per cent) of 203 isolated chyle leaks and 90 (70·3 per cent) of 128 coincidental chyle leaks resolved with conservative management within 14 days. Initial and maximum drainage volumes were associated with duration of hospital stay and success of therapy by 14 days. Impact on survival was restricted to chyle leaks that persisted at 14 days in patients with cancer undergoing palliative surgery.

Conclusion

Chyle leak is a relevant complication, with an incidence of more than 10 per cent after pancreatic surgery, and has a major impact on hospital stay. Drainage volume is associated with hospital stay and success of therapy.

Management of high-output chylous ascites after D2-lymphadenectomy in patients with gastric cancer: a multi-center study

BACKGROUND

This study aimed to propose treatment strategies for high-output chylous ascites (CA) developed after gastric cancer surgery.

METHODS

The data of patients with CA after gastric cancer surgery in three high volume Training and Research Hospitals between 2005 and 2015 were retrospectively evaluated.

RESULTS

Nine patients out of 436 gastrectomies were detected with CA. The mean amount of daily fistula output was 939 mL. Treatment consisted of cessation of oral feeding, total parenteral nutrition (TPN), somatostatin analogs administration, clamping and/or removal of the drainage tube, diuretic administration and diet therapy with medium-chain triglycerides (MCTs) alone or in combination. The mean fistula closure time and length of hospital stay were 23 and 24 days respectively. Hemopneumothorax developed during right subclavian vein catheterisation for TPN implementation in one patient. There was no mortality.

CONCLUSIONS

Combined cessation of oral feeding and TPN are usually used for treatment of CA as first-line treatment. However, TPN is no harmless. Although our data are limited they do allow us to conclude that diet with MCT's may use for medical treatment of CA as first-line.

The application of nutrition support in conservative treatment of chylous ascites after abdominal surgery

BACKGROUND

Chylous ascites is the pathologic leakage of triglycerides-rich lymphatic fluid into the peritoneal cavity. Chylous ascites is a rare complication in abdominal surgery. This study aimed to find a relatively better method for nutrition support in the treatment of chylous ascites after abdominal surgery.

METHODS

This study was a retrospective study. This study retrospectively reviewed patients who underwent abdominal surgery and developed chylous ascites, from the year 2010 to 2014, at the West China Hospital of Sichuan University and the Affiliated Hospital of Zunyi Medical College. Fifty-eight patients who developed chylous ascites after abdominal surgery were included in the study. The clinical effect of somatostatin was evaluated. The differences in the curative efficacy among a daily diet, a low-fat diet supplemented with medium-chain triglyceride (MCT), and total parenteral nutrition (TPN) were also analyzed in this study.

RESULTS

Complete clinical success was reached earlier in patients treated with somatostatin (P<0.001). The tube removal time, the time to resumption of an oral diet, and the length of hospital stay after chylous leakage were significantly different between patients treated with and without somatostatin. The curative efficacies of the enteral nutrition (EN) + MCT plan and the TPN plan were quite similar, with no significant difference, however, were significantly different from the MCT regime, which was the worst. However, using the EN + MCT plan was more cost-effective (P=0.038).

CONCLUSION

In treating chylous ascites, EN + MCT instead of TPN was the best nutrition support. Moreover, somatostatin or its analog octreotide should be used immediately. The treatment with somatostatin in combination with EN + MCT is recommended in the conservative treatment of postoperative chylous ascites.

Changes over time in milk test results following pancreatectomy

AIM: To investigate changes over time in, and effects of sealing technology on, milk test results following pancreatectomy.

METHODS: From April 2008 to October 2013, 66 pancreatic resections were performed at the Iwakuni Clinical Center. The milk test has been routinely conducted at the institute whenever possible during pancreatectomy. The milk test comprises the following procedure: A nasogastric tube is inserted until the third portion of the duodenum, followed by injection of 100 mL of milk through the tube. If a chyle leak is present, the patient tests positive in this milk test based on the observation of a white milky discharge. Positive milk test rates, leakage sites, and chylous ascites incidence were examined. LigaSure™ (LS; Covidien, Dublin, Ireland), a vessel-sealing device, is routinely used in pancreatectomy. Positive milk test rates before and after use of LS, as well as drain discharge volume at the 2^nd and 3^rd postoperative days, were compared retrospectively. Finally, positive milk test rates and chylous ascites incidence were compared with the results of a previous report.

RESULTS: Fifty-nine milk tests were conducted during pancreatectomy. The positive milk test rate for all pancreatectomy cases was 13.6% (8 of 59 cases). One case developed postoperative chylous ascites (2.1% among the pancreatoduedenectomy cases and 1.7% among all pancreatectomies). Positive rates by procedure were 12.8% for pancreatoduodenectomy and 22.2% for distal pancreatectomy. Positive rates by disease were 17.9% for pancreatic and 5.9% for biliary diseases. When comparing results from before and after use of LS, positive milk test rates in pancreatoduodenectomy were 13.0% before and 12.5% after, while those in distal pancreatectomy were 33.3% and 0%. Drainage volume tended to decrease when LS was used on the 3^rd postoperative day (volumes were 424 ± 303 mL before LS and 285 ± 185 mL after, P = 0.056). Both chylous ascites incidence and positive milk test rates decreased slightly compared with those rates from the previous study.

CONCLUSION: Positive milk test rates and chylous ascites incidence decreased over time. Sealing technology may thus play an important role in preventing postoperative chylous ascites.

Feeding patients with preoperative symptoms of gastric outlet obstruction after pancreatoduodenectomy: Early oral or routine nasojejunal tube feeding?

BACKGROUND

Early oral feeding is currently considered the optimal routine feeding strategy after pancreatoduodenectomy (PD). Some have suggested that patients with preoperative symptoms of gastric outlet obstruction (GOO) who undergo PD have such a high risk of developing delayed gastric emptying that these patients should rather receive routine postoperative tube feeding. The aim of this study was to determine whether clinical outcomes after PD in these patients differ between postoperative early oral feeding and routine tube feeding.

METHODS

We analyzed a consecutive multicenter cohort of patients with preoperative symptoms of GOO undergoing PD (2010-2013). Patients were categorized into two groups based on the applied postoperative feeding strategy (dependent on their center's routine strategy): early oral feeding or routine nasojejunal tube feeding.

RESULTS

Of 497 patients undergoing PD, 83 (17%) suffered from preoperative symptoms of GOO. 49 patients received early oral feeding and 29 patients received routine tube feeding. Time to resumption of adequate oral intake (primary outcome; 14 vs. 12 days, p = 0.61) did not differ between these two feeding strategies. Furthermore, overall complications and length of stay were similar in both groups. Of the patients receiving early oral feeding, 24 (49%) ultimately required postoperative tube feeding. In patients with an uncomplicated postoperative course, early oral feeding was associated with shorter time to adequate oral intake (8 vs. 12 days, p = 0.008) and shorter hospital stay (9 vs. 13 days, p < 0.001).

CONCLUSION

Also in patients with preoperative symptoms of GOO, early oral feeding can be considered the routine feeding strategy after PD.

Treatment options for chylous ascites after major abdominal surgery: a systematic review

BACKGROUND

Chylous leakage is a relevant clinical problem after major abdominal surgery leading to an increased length of stay.

DATA SOURCES

A systematic search of MEDLINE/PubMed and the Cochrane Library was performed according to the PRISMA statement. The search for the MeSH terms "chylous ascites" and/or "lymphatic fistula" retrieved a total of 2,348 articles, of which 36 full-text articles were reviewed by 2 independent investigators.

RESULTS

Chylous ascites is described with an incidence of up to 11%, especially after pancreatic surgery. The incidence is increasing with the number of lymph nodes harvested. In patients treated with total parenteral nutrition, conservative treatment is demonstrated to be effective in up to 100% of cases.

CONCLUSIONS

The extent of abdominal surgery mainly predicts the risk of chylous ascites. Conservative treatment has been shown to be effective in almost all cases and is the treatment of choice.