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Jog A, Schmidt P, Hallal PL, Novitch R. Chylothorax: A Late Complication of Disseminated Mycobacterium avium Complex (MAC) Infection. Cureus 2023; 15:e40347. [PMID: 37456383 PMCID: PMC10339148 DOI: 10.7759/cureus.40347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 07/18/2023] Open
Abstract
Chylothorax is a rare cause of pleural effusion and occurs due to leakage of chyle into the pleural space. In most cases, it results from trauma, with malignancy accounting for most of the non-traumatic causes. Chylothorax resulting from immune reconstitution inflammatory syndrome (IRIS), during treatment of Mycobacterium avium complex (MAC) infection, is an extremely infrequent cause of chylothorax, with only a handful of cases reported in the literature.
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Affiliation(s)
- Abhishrut Jog
- Pulmonary Medicine, BronxCare Health System, Bronx, USA
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2
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Duletzke NT, Kiraly LN, Martindale RG. Chylothorax and chylous ascites: Overview, management, and nutrition. Nutr Clin Pract 2023; 38:557-563. [PMID: 36938719 DOI: 10.1002/ncp.10973] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 03/21/2023] Open
Abstract
Chyle leaks of any source or type can cause significant morbidity and mortality. Attention to the anatomy and physiology of the leak, followed by stepwise dietary and pharmacologic management, obviates the need for surgical intervention in a majority of patients. In this article, we review the importance, etiology, anatomy, diagnosis, nutrition and immunologic effects, and options for treatment of chylothorax and chylous ascites based on experience and prior literature. We propose a multidisciplinary approach to optimize these treatments including the primary surgical teams, pharmacists, and dietitians, with reoperation as a last resort to minimize the morbidity of this challenging complication.
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Affiliation(s)
- Nicholas T Duletzke
- Department of Surgery, Oregon Health and Science University, Oregon, Portland, USA
| | - Laszlo N Kiraly
- Department of Surgery, Oregon Health and Science University, Oregon, Portland, USA
| | - Robert G Martindale
- Department of Surgery, Oregon Health and Science University, Oregon, Portland, USA
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3
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Agrawal A, Chaddha U, Kaul V, Desai A, Gillaspie E, Maldonado F. Multidisciplinary Management of Chylothorax. Chest 2022; 162:1402-1412. [PMID: 35738344 DOI: 10.1016/j.chest.2022.06.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 05/04/2022] [Accepted: 06/10/2022] [Indexed: 12/14/2022] Open
Abstract
Chylothorax, the accumulation of chyle in the pleural space, is usually caused by the disruption of the thoracic duct or its tributaries. Etiologies are broadly divided into traumatic, including postsurgical, and nontraumatic, most commonly in the setting of malignancy. The management of chylothorax largely depends on the cause and includes dietary modification and drainage of the pleural space. A definitive intervention, whether surgical or a percutaneous lymphatic intervention, should be considered in patients with a persistently high volume of chylous output and in those with a prolonged leak, before complications such as malnutrition ensue. No methodologically robust clinical trials guiding management are currently available. In this article, we review the current literature and propose a stepwise, evidence-based multidisciplinary approach to the management of patients with both traumatic and nontraumatic chylothorax.
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Affiliation(s)
- Abhinav Agrawal
- Interventional Pulmonology, Division of Pulmonary, Critical Care & Sleep Medicine, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY.
| | - Udit Chaddha
- Interventional Pulmonology, Division of Pulmonary, Critical Care & Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Viren Kaul
- Division of Pulmonary and Critical Care Medicine, Crouse Health/SUNY Upstate Medical University, Syracuse, NY
| | - Ajinkya Desai
- Interventional Radiology, Department of Radiology, University of Mississippi Medical Center, Jackson, MS
| | - Erin Gillaspie
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Fabien Maldonado
- Interventional Pulmonology, Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
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4
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Kim BS, Seo Y, Kang CM. Alternative management of intractable chylous ascites following robot-assisted pancreaticoduodenectomy of Viscum album sclerotherapy: a case report. KOREAN JOURNAL OF CLINICAL ONCOLOGY 2022; 18:78-82. [PMID: 36945246 PMCID: PMC9942760 DOI: 10.14216/kjco.22010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 12/14/2022] [Accepted: 12/15/2022] [Indexed: 12/31/2022]
Abstract
A patient showed signs of fever and Hemovac insertion site discharge 8 days after surgery and was admitted. Abdominal paracentesis found milky ascites with triglyceride levels of the peritoneal fluid as high as 1,603 g/mL. Diagnosed as chylous ascites, symptomatic therapy such as empirical antibodies and diuretics was administered with paracentesis before being discharged. The ascites volume increased again, and the patient was re-admitted. The patient was treated with orlistat, octreotide, total parenteral nutrition administration, ascites drainage, and diuretics. Ascites levels increased further and intraperitoneal Viscum was administered. Clear ascites was observed, and the patient was discharged. We reported a case where conventional treatment for chylous ascites that occurred after pancreaticoduodenectomy was shown to be ineffective while Viscum extracted from mistletoe was able to manage chylous ascites.
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Affiliation(s)
- Beom Soo Kim
- Yonsei University College of Medicine, Seoul,
Korea
| | - Youngbin Seo
- Yonsei University College of Medicine, Seoul,
Korea
| | - Chang Moo Kang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul,
Korea
- Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul,
Korea
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5
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Ur Rehman K, Sivakumar P. Non-traumatic chylothorax: diagnostic and therapeutic strategies. Breathe (Sheff) 2022; 18:210163. [PMID: 36337134 PMCID: PMC9584559 DOI: 10.1183/20734735.0163-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 05/31/2022] [Indexed: 12/04/2022] Open
Abstract
Non-traumatic chylothorax refers to accumulation of chyle in the pleural space in the absence of any traumatic disruption to the thoracic duct. Chyle originates from the intestines and is transported via the thoracic duct into systemic circulation. The anatomical course of the thoracic duct is complex with considerable variation; therefore, development of chylothorax is dependent on the site and level of the thoracic duct defect. Non-traumatic chylothorax is associated with a wide range of medical disorders, but malignancy accounts for three-quarters of cases. In up to 9% of cases, the aetiology remains unknown (termed idiopathic chylothorax). Gross appearance of pleural fluid is neither sensitive nor specific enough to diagnose chylothorax; therefore, biochemical analysis of the pleural fluid is required. Pleural fluid triglyceride level >1.24 mmol·L−1 (110 mg·dL−1) with a cholesterol level <5.18 mmol·L−1 (200 mg·dL−1) is diagnostic of chylothorax. In borderline cases, lipoprotein electrophoresis can help confirm the diagnosis by detecting chylomicrons in the pleural fluid. Once the diagnosis of chylothorax is confirmed, the next step is to find the cause and identify the leakage point, for which various lymphatic specific radiological investigations may have an important role. There is paucity of data on the most suitable approach to manage non-traumatic chylothoraces and treatment often depends on the underlying cause. In general, conservative treatment is tried first, usually for a limited time, before considering more invasive measures. A multidisciplinary approach is recommended with close liaison among the respiratory physicians, thoracic surgeons, oncologists, interventional radiologists, dietitians and pharmacists. Non-traumatic chylothorax is associated with a myriad of medical disorders. Lipid analysis of pleural fluid is required to confirm the diagnosis. A multidisciplinary approach is recommended for the effective management of non-traumatic chylothorax. https://bit.ly/3Nssb7n
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6
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The Development of Chylothorax in a Child With T-cell Lymphoblastic Lymphoma and Ataxia Telangiectasia During Induction Therapy. J Pediatr Hematol Oncol 2022; 44:e554-e556. [PMID: 33370001 DOI: 10.1097/mph.0000000000002039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 11/18/2020] [Indexed: 11/26/2022]
Abstract
Chylothorax is an unusual complication of childhood cancer. It causes to additional morbidity and mortality during management. It should be kept in mind that chylothorax may occur due to mass shrinkage during treatment in patients with mediastinal mass and ductus thoracicus invasion at the initial diagnosis and necessary measures should be taken. This case was presented because of the rarity in pediatric oncology practice.
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7
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Lau ACW, Hsu PYH, Ng D, Luecke K, Nayar S. Management of Malignant Chylothorax with Subcutaneous Octreotide Treatment. J Pain Palliat Care Pharmacother 2021; 35:48-51. [PMID: 33600270 DOI: 10.1080/15360288.2021.1883180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
There are currently limited published case reports and clinical studies looking at octreotide as a potential therapeutic agent for treating surgery- and malignancy-related chylothorax in adult patients. Few case reports have shown that low-dose subcutaneous octreotide can be used to treat malignant chylothorax. We report the case of a 57-year-old high-grade follicular lymphoma patient with malignant chylothorax which responded rapidly and was successfully treated with octreotide. Significant improvements were noted in her dyspnea, abdominal distention and pain, and chylous output. This case also highlights the importance of understanding the pharmacotherapeutic effects of octreotide when managing malignant chylothorax as it may help to benefit patients by improving symptoms, quality of life, and length of hospital stay. Further prospective studies are warranted to further evaluate the role of octreotide in the management of malignant chylothorax.
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8
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Ghimire S, Shah H, Paudel S, Yang TJ, Khan HM. Chylous Ascites and Pleural Effusion Treated With Intravenous Octreotide. Cureus 2020; 12:e8669. [PMID: 32699669 PMCID: PMC7370588 DOI: 10.7759/cureus.8669] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 06/17/2020] [Indexed: 12/23/2022] Open
Abstract
Chylous ascites (CA) is uncommon in cirrhosis. It often presents as diuretic-resistant ascites and is associated with increased mortality. Diagnosis is done by the detection of triglyceride-rich ascitic fluid. There are no published guidelines on the management of CA. We describe the case of a middle-aged female who presented with CA secondary to cirrhosis, and the challenges associated with her treatment and her management with the use of intravenous octreotide.
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Affiliation(s)
- Subash Ghimire
- Internal Medicine, Guthrie Clinic, Robert Packer Hospital, Sayre, USA
| | | | - Sanjay Paudel
- Medicine, B.P. Koirala Institute of Health Sciences, Dharan, NPL
| | - Tsu Jung Yang
- Internal Medicine, MultiCare Good Samaritan Hospital, Puyallup, USA
| | - Hafiz M Khan
- Gastroenterology and Hepatology, Guthrie Clinic, Robert Packer Hospital, Sayre, USA
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9
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Kostov S, Yordanov A, Slavchev S, Strashilov S, Dzhenkov D. First Case of Chylous Ascites after Laparoscopic Myomectomy: A Case Report with a Literature Review. MEDICINA (KAUNAS, LITHUANIA) 2019; 55:E624. [PMID: 31547593 PMCID: PMC6843166 DOI: 10.3390/medicina55100624] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 09/16/2019] [Accepted: 09/18/2019] [Indexed: 12/12/2022]
Abstract
Introduction: Chylous ascites is a rare form of ascites characterized by milk-like peritoneal fluid, rich in triglycerides. Clinical signs and symptoms include abdominal distention, pain, nausea, and vomiting. In gynecology, the most common cause for its occurrence is lymph dissection leading to impairment of major lymphatic vessels. There are only a few reported cases of chylous ascites arising after operations for benign diseases. Case report: We report a case of a 46-year-old female patient, who underwent laparoscopy for a myomatous node with chylous ascites occurring on post-surgery Day 2. The ascites was conservatively managed. The exact cause of the chyloperitonitis could not be determined. Conclusion: Although extremely rarely, chylous ascites may also occur in operative interventions for benign diseases in gynecological surgery.
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Affiliation(s)
- Stoyan Kostov
- Department of Gynecology, Medical University Varna, 9000 Varna, Bulgaria.
| | - Angel Yordanov
- Department of Gynecologic Oncology, Medical University Pleven, 5800 Pleven, Bulgaria.
| | - Stanislav Slavchev
- Department of Gynecology, Medical University Varna, 9000 Varna, Bulgaria.
| | - Strahil Strashilov
- Department of Plastic Restorative, Reconstructive and Aesthetic Surgery, Medical University Pleven, 5800 Pleven, Bulgaria.
| | - Deyan Dzhenkov
- Department of General and Clinical pathology, Forensic Medicine and Deontology, Medical University Varna, 9002 Varna, Bulgaria.
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10
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Refractory Chylothorax: Where Do We Go Now? CURRENT PULMONOLOGY REPORTS 2019. [DOI: 10.1007/s13665-019-0226-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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11
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Chylous Cardiac Tamponade with Chylothoraces Secondary to Hodgkin's Lymphoma: Octreotide in Conjuncture with Standard of Care Dietary Fat Restriction. Case Rep Crit Care 2019; 2019:1406840. [PMID: 31019812 PMCID: PMC6452529 DOI: 10.1155/2019/1406840] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 02/10/2019] [Accepted: 02/17/2019] [Indexed: 11/17/2022] Open
Abstract
Chylous effusions are a well-known complication from a variety of etiologies including trauma, malignancies, and anatomic defects, with the most common location being in the pleural space. A pericardial chylous effusion (chylopericardium) is uncommon, and a chylopericardium with concomitant bilateral chylous pleural effusions (chylothoraces) has only been reported in less than a handful of case reports. Our patient presented with bilateral chylothoraces and a chylopericardium with tamponade physiology secondary to Hodgkin's Lymphoma. In this article, we discuss our treatment of this patient with the somatostatin analogue octreotide, as well as the standard of care dietary fat restriction, in order to control these effusions until the patient's chemotherapy took effect.
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12
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Gupta A, Singh T. Octreotide in malignant chylothorax: a case report. BMJ Support Palliat Care 2015; 6:122-4. [DOI: 10.1136/bmjspcare-2015-000933] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 11/12/2015] [Indexed: 01/31/2023]
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13
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Alzaman N, Pittas AG, O'Leary M, Ceglia L. Post-thyroidectomy hypocalcemia exacerbated by chyle leak. Endocrinol Diabetes Metab Case Rep 2015; 2015:140110. [PMID: 25861451 PMCID: PMC4360596 DOI: 10.1530/edm-14-0110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 02/05/2015] [Indexed: 11/08/2022] Open
Abstract
Transient hypocalcemia after thyroidectomy is not uncommon and the risk increases with the extent of neck surgery. We report a case of severe and prolonged hypocalcemia after total thyroidectomy complicated by thoracic duct injury. Hypoparathyroidism and thoracic duct injury are potential complications following total thyroidectomy with extensive lymph node dissection. This case suggested that having both conditions may complicate treatment of hypoparathyroid-induced hypocalcemia by way of losses of calcium and vitamin D in the chyle leak.
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Affiliation(s)
- Naweed Alzaman
- Division of Endocrinology, Diabetes, and Metabolism , Tufts Medical Center , 800 Washington Street, Boston, Massachusetts, 02111 , USA
| | - Anastassios G Pittas
- Division of Endocrinology, Diabetes, and Metabolism , Tufts Medical Center , 800 Washington Street, Boston, Massachusetts, 02111 , USA
| | - Miriam O'Leary
- Department of Otolaryngology , Tufts Medical Center , 800 Washington Street, Boston, Massachusetts, 02111 , USA
| | - Lisa Ceglia
- Division of Endocrinology, Diabetes, and Metabolism , Tufts Medical Center , 800 Washington Street, Boston, Massachusetts, 02111 , USA
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Zhao Y, Hu W, Hou X, Zhou Q. Chylous Ascites After Laparoscopic Lymph Node Dissection in Gynecologic Malignancies. J Minim Invasive Gynecol 2014; 21:90-6. [DOI: 10.1016/j.jmig.2013.07.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 07/09/2013] [Accepted: 07/09/2013] [Indexed: 12/23/2022]
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16
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Matsuda T, Fujita H, Kunimoto Y, Kimura T, Ogino K. Chylous ascites as a complication of laparoscopic colorectal surgery. Asian J Endosc Surg 2013; 6:279-84. [PMID: 23941730 DOI: 10.1111/ases.12057] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2013] [Revised: 07/09/2013] [Accepted: 07/22/2013] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
- Takeru Matsuda
- Department of Surgery, Seirei Mikatahara General Hospital, Hamamatsu, Japan
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17
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Karaca S, Gemayel G, Kalangos A. Somatostatin treatment of a persistent chyloperitoneum following abdominal aortic surgery. J Vasc Surg 2012; 56:1409-12. [PMID: 22999046 DOI: 10.1016/j.jvs.2012.05.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Revised: 05/01/2012] [Accepted: 05/03/2012] [Indexed: 12/23/2022]
Abstract
Chyloperitoneum is an uncommon but serious complication of abdominal aortic surgery. There are no optimal guidelines for the management of chyloperitoneum. We present here our experiences regarding the treatment of chyloperitoneum with somatostatin for three patients who underwent surgery for abdominal aortic disease. Milky, odorless liquid was observed in the abdominal drain of these patients. The conservative treatment with total parenteral nutrition failed; therefore, in parallel, we initiated a somatostatin treatment as a continuous perfusion. Drain loss decreased in all up to the second day of treatment. The probable mechanisms of the somatostatin decrease the intestinal absorption of fats via the specific receptors, decrease triglyceride concentration in the thoracic duct, and attenuate lymph flow in the major lymphatic channels. The presented cases showed successful treatment using somatostatin and may be a new generation of effective treatments for chyloperitoneum.
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Affiliation(s)
- Saziye Karaca
- Department of Cardiovascular Surgery, University Hospital of Geneva, Geneva, Switzerland.
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18
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Abstract
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.
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Affiliation(s)
- Darius L Lazarus
- Department of Medicine, McGill University, Montreal, Que., Canada
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Nakayama G, Morioka D, Murakami T, Takakura H, Miura Y, Togo S. Chylous ascites occurring after low anterior resection of the rectum successfully treated with an oral fat-free elemental diet (Elental(®)). Clin J Gastroenterol 2012; 5:216-9. [PMID: 22773935 PMCID: PMC3382280 DOI: 10.1007/s12328-012-0304-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2012] [Accepted: 04/06/2012] [Indexed: 12/26/2022]
Abstract
Chylous ascites occurring after abdominal surgery is rare. Despite being potentially critical, there is no definite treatment guideline because of its rarity. Here we present a case of massive chylous ascites occurring after rectal surgery which was successfully treated with an oral fat-free elemental diet (ED). A 67-year-old man underwent low anterior resection with para-aortic lymphadenectomy for advanced rectal cancer. Early postoperative course was uneventful and the patient was discharged from hospital 10 days after surgery; however, after discharge, abdominal distension rapidly developed. Abdominal computed tomography (CT) performed 3 weeks after surgery revealed massive ascites and laboratory findings showed remarkable hypoproteinemia and lymphopenia. Urgent diagnostic paracentesis showed the ascites to be a white milky fluid containing high levels of triglycerides (564 mg/dl), leading to a diagnosis of chyloperitoneum. Daily nutrition of the patient was entirely with a fat-free ED (30 kcal/kg/day of Elental(®), Ajinomoto Pharmaceutical Co. Ltd, Tokyo, Japan). After the initiation of oral Elental(®), abdominal distension, hypoproteinemia, and lymphopenia gradually improved. Abdominal CT performed 7 weeks after surgery showed no ascitic fluid in the abdomen, and thereafter a normal diet was initiated. Since then, no relapse of chyloperitoneum has been proven. As a result, the chylous ascites was successfully treated in the outpatient clinic.
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Affiliation(s)
- Gakuryu Nakayama
- Department of Surgery, Yokohama Ekisaikai Hospital, 1-2 Yamada-cho, Naka-ku, Yokohama, 231-0036 Japan
| | - Daisuke Morioka
- Department of Surgery, Yokohama Ekisaikai Hospital, 1-2 Yamada-cho, Naka-ku, Yokohama, 231-0036 Japan
| | - Takashi Murakami
- Department of Surgery, Yokohama Ekisaikai Hospital, 1-2 Yamada-cho, Naka-ku, Yokohama, 231-0036 Japan
| | - Hideki Takakura
- Department of Surgery, Yokohama Ekisaikai Hospital, 1-2 Yamada-cho, Naka-ku, Yokohama, 231-0036 Japan
| | - Yasuhiko Miura
- Department of Surgery, Yokohama Ekisaikai Hospital, 1-2 Yamada-cho, Naka-ku, Yokohama, 231-0036 Japan
| | - Shinji Togo
- Department of Surgery, Yokohama Ekisaikai Hospital, 1-2 Yamada-cho, Naka-ku, Yokohama, 231-0036 Japan
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20
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Postoperative chylous ascites after colorectal cancer surgery. Surg Today 2012; 42:724-8. [PMID: 22327283 DOI: 10.1007/s00595-012-0132-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Accepted: 06/17/2011] [Indexed: 12/15/2022]
Abstract
PURPOSE To evaluate the diagnosis, epidemiology, risk factors, and treatment of chylous ascites after colorectal cancer surgery. METHODS Among 907 patients who underwent colorectal cancer resection at our institution between 2006 and 2009, chylous ascites developed in 9. We analyzed the clinical data for these 9 patients. RESULTS Five of the nine patients with chylous ascites had undergone right hemicolectomy and seven had undergone D3 lymph node dissection. In all patients, chylous ascites began to develop the day after commencement of oral intake or the next day. Two patients had no change in diet, one was started on a high-protein and low-fat diet, and six were put on intestinal fasting. Drainage tubes were removed within 5 days after treatment in seven patients. The hospital stay was about 2 weeks after surgery and 1 week after treatment. We found that the tumor area, tumors fed by the superior mesenteric artery, and D3 lymph node dissection were significantly associated with chylous ascites. CONCLUSIONS Chylous ascites after colorectal cancer surgery occurred at an incidence of 1.0%, but was significantly more frequent after surgery for tumors fed by the superior mesenteric artery and after D3 lymph node dissection. Conservative treatment was effective in all cases.
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21
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Idiopathic chylous ascites treated with total parenteral nutrition and octreotide. A case report and review of the literature. Eur J Gastroenterol Hepatol 2011; 23:961-3. [PMID: 21817913 DOI: 10.1097/meg.0b013e328349aa2d] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Chylous ascites is the accumulation of lipid-rich lymph in the peritoneal cavity. The usual cause in adults is lymphatic obstruction or leakage caused by malignancy. Non-malignant causes include postoperative trauma, cirrhosis, tuberculosis, pancreatitis and filariasis. A variety of treatment options have been proposed for the management of chylous ascites; however, their effectiveness in idiopathic or primary form is unknown. Here we report a case of chylous acid rapidly resolved with the treatment of fasting, total parenteral nutrition and somatostatin analogue.
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Rodier JF, Volkmar PP, Bodin F, Frigo S, Ciftci S, Dahlet C. Thoracic duct fistula after thyroid cancer surgery: towards a new treatment? Case Rep Oncol 2011; 4:255-9. [PMID: 21734879 PMCID: PMC3124458 DOI: 10.1159/000328801] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The use of somatostatin analogs is a new conservative therapeutic approach for the treatment of chyle fistulas developing after thyroid cancer surgery. The combination therapy with a total parenteral nutrition should avoid the high morbidity of a re-intervention with an uncertain outcome. This promising trend is supported by the present case report of a chyle leak occurring after total thyroidectomy with central and lateral neck dissection for a papillary carcinoma, which was treated successfully without immediate or distant sequelae.
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A novel perspective for an orphan problem: old and new drugs for the medical management of malignant ascites. Crit Rev Oncol Hematol 2010; 79:144-53. [PMID: 20708947 DOI: 10.1016/j.critrevonc.2010.07.016] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2010] [Revised: 07/13/2010] [Accepted: 07/16/2010] [Indexed: 12/18/2022] Open
Abstract
Malignant ascites is defined as a condition in which fluid containing cancer cells accumulates in the abdomen. The cancers most commonly associated to ascites are ovarian (37%), pancreato-biliary (21%), gastric (18%), oesophageal (4%), colorectal (4%), and breast (3%). Treatment of malignant ascites remains a challenge. In the majority of patients systemic chemotherapy is ineffective and diuretics and paracentesis are still the only approaches, but new promising option are appearing, as cytoreductive debulking surgery and intraperitoneal (IP) or intravenous biological (target) therapies. More promising, after the recognition of potential epithelial targets as Epithelial Cell Adhesion Molecule (EpCAM), are the trifunctional antibodies able to bind these cell adhesion molecules and, at the same, time the immune system cells. These agents have been developed for malignant ascites with the aim also to prolong the need for subsequent paracentesis. So patients with malignant ascites may look at the future with hope and growing optimism.
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Affiliation(s)
- Eva Murphy
- University of Nottingham, Nottingham, United Kingdom
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Zhou DX, Zhou HB, Wang Q, Zou SS, Wang H, Hu HP. The effectiveness of the treatment of octreotide on chylous ascites after liver cirrhosis. Dig Dis Sci 2009; 54:1783-8. [PMID: 19051030 DOI: 10.1007/s10620-008-0566-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2008] [Accepted: 09/26/2008] [Indexed: 12/09/2022]
Abstract
Octreotide is a crucial drug used for treating patients with chylous ascites; however, there have been few reports related to octreotide that are being used in cirrhotic patients. Thus, this thesis is designed to determine the effects of octreotide on patients with chylous ascites after liver cirrhosis. Eight patients were diagnosed with chylous ascites, on the basis of laboratory findings on ascites samples, between January 2003 and May 2008. Octreotide was given to the six patients, while the remaining two were treated as a control. All patients had persistent peritoneal drainage with the quantity and quality of the drainage fluid observed once every other day. All the necessary care was individually given to the patients during the therapy. All patients properly received combined therapy including a low-fat and low-sodium diet, and diuretic and peritoneal drainage. The volume of the peritoneal drainage was reduced to zero in one of the six patients who received octreotide therapy, while the other five had the drainage volumes decreased from 2,000 to 50 ml with a clear appearance and negative qualitative analysis of chyle. For those two patients who did not receive octreotide therapy, the conditions of peritoneal drainage seldom changed both from the qualitative and quantitative aspects. In conclusion, Octreotide, along with combined therapy, can rapidly relieve portal hypertension and reduce triglyceride levels in ascites. It appears to be an effective therapy available for the treatment of chylous ascites caused by liver cirrhosis.
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Affiliation(s)
- Dong Xun Zhou
- Department of Comprehensive Treatment II, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, 225 Changhai Road, Shanghai, China.
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26
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Gomes CS, Handa GI, Silveira FP, Buzingnani VZ, Binati FM, Rasera ESL. Tratamento cirúrgico da ascite quilosa. J Vasc Bras 2009. [DOI: 10.1590/s1677-54492009000200017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
A ascite quilosa é uma complicação rara após procedimentos cirúrgicos e trauma abdominal, apresentando elevada morbidade e difícil manejo. Nos casos refratários ao tratamento clínico habitual, o tratamento cirúrgico se impõe, apesar da baixa taxa de sucesso. Dois casos são apresentados: o primeiro paciente foi vítima de trauma abdominal contuso e o segundo foi submetido a hernioplastia hiatal a Nissen videolaparoscópica, ambos evoluindo com ascite quilosa que necessitou de tratamento cirúrgico através da ligadura do ducto torácico, junto aos pilares diafragmáticos. Os pacientes evoluíram com melhora clínica e ausência de ascite após 24 meses de seguimento.
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Soto R, García I, Hinojosa C, Torre A. Refractory Chylous Ascites. Gastroenterology Res 2008; 1:57-59. [PMID: 27994709 PMCID: PMC5154218 DOI: 10.4021/gr2008.11.1252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2008] [Accepted: 12/03/2008] [Indexed: 12/23/2022] Open
Abstract
A 34-year-old woman with primary chylous ascites due to lymphangiectasias was treated with sclerotherapy of dilated lymphatics and a lymphovenous shunt. She was referred to our institution after a thorough diagnostic and therapeutic approach in her community hospital. After four weeks of intensive diagnostic study, no secondary etiology for her chylous disorder was established. Conservative treatment did not prove useful, and a laparotomy was done. Lymphangiectasias and a lymphatic leak were demonstrated, but primary closure was ineffective. A second surgery with derivative intention was done, but six months later ascites recurred. A new sclerosing surgery was done; afterwards, the patient remained free of symptoms. Primary chyloperitoneum is a rare and complex disorder; its treatment and outcome depend on a multidisciplinary approach and an experienced medical team.
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Affiliation(s)
- Rodrigo Soto
- Instituto Nacional de Ciencias Medicas y Nutricion "Salvador Zubiran" Vasco de Quiroga # 15, Col. Seccion XVI, Tlalpan, D. F. CP 14000, Mexico
| | - Ignacio García
- Instituto Nacional de Ciencias Medicas y Nutricion "Salvador Zubiran" Vasco de Quiroga # 15, Col. Seccion XVI, Tlalpan, D. F. CP 14000, Mexico
| | - Carlos Hinojosa
- Instituto Nacional de Ciencias Medicas y Nutricion "Salvador Zubiran" Vasco de Quiroga # 15, Col. Seccion XVI, Tlalpan, D. F. CP 14000, Mexico
| | - Aldo Torre
- Instituto Nacional de Ciencias Medicas y Nutricion "Salvador Zubiran" Vasco de Quiroga # 15, Col. Seccion XVI, Tlalpan, D. F. CP 14000, Mexico
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Chung M, Kozuch P. Treatment of malignant ascites. Curr Treat Options Oncol 2008; 9:215-33. [PMID: 18777213 DOI: 10.1007/s11864-008-0068-y] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2008] [Accepted: 07/28/2008] [Indexed: 12/11/2022]
Abstract
OPINION STATEMENT The management of malignant ascites is a significant challenge in gastrointestinal medical oncology. Current treatment strategies include diuretic therapy, paracentesis, peritoneal drains, and venous shunts. However, there are no established evidence-based guidelines, and there is a lack of randomized controlled trials identifying optimal therapy. Newer therapies are emerging and will need further study. By summarizing published studies, this review is intended to add some clarity to currently available strategies for the management of malignant ascites associated with hepatobiliary cancers. Notably, however, much of the available data for the management of malignant ascites comes from the gynecologic oncology experience, specifically from studies in ovarian cancer. Therefore, successful approaches used in this malignancy may be lead candidates for development in hepatobiliary cancer-associated ascites and are reviewed in this paper.
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Giovannini I, Giuliante F, Chiarla C, Giordano M, Ardito F, Vellone M, Sarno G, Nuzzo G. External lymphatic fistula after intra-abdominal lymphadenectomy for cancer. Treatment with total parenteral nutrition and somatostatin. Nutrition 2008; 24:1220-3. [PMID: 18639440 DOI: 10.1016/j.nut.2008.05.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2008] [Revised: 05/05/2008] [Accepted: 05/30/2008] [Indexed: 12/26/2022]
Abstract
OBJECTIVE External lymphatic fistula or chyloperitoneum after intra-abdominal lymphadenectomy may present challenging problems. In the absence of definite guidelines the choice of treatment is often empirical, with unpredictable effectiveness, and the reporting of new cases may broaden the available experience. METHODS We describe two cases. One patient had high-output external fistula (1300 mL/d) after para-aortic lymphadenectomy for metastatic lymph nodes. The fistula became fully evident at postoperative day 4, with resumption of an oral diet, on the basis of a 1300-mL/d output of white milky fluid from an abdominal drainage. Oral feeding was interrupted and total parenteral nutrition was started; this was transiently associated with octreotide administration, subsequently replaced by somatostatin. The second patient had a low-output fistula (350 mL/d) after liver resection and lymphadenectomy for cholangiocarcinoma and underwent treatment with total parenteral nutrition and somatostatin. RESULTS In the first case the lymphatic fistula healed in just less than 3 wk, with the patient constantly remaining in very good condition, without secondary complications. In the second case the low-output fistula healed more rapidly. CONCLUSION Interruption of oral feeding with total parenteral nutrition and continuous somatostatin infusion was an effective treatment in both patients with an intra-abdominal lymphatic leak.
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Affiliation(s)
- Ivo Giovannini
- Department of Surgery, Hepatobiliary Unit, Catholic University of the Sacred Heart School of Medicine, Rome, Italy.
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30
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Abstract
PURPOSE OF REVIEW This article reviews the current literature concerning the role of somatostatin and its synthetic analogue, octreotide, in the treatment of chylothorax. RECENT FINDINGS Management of chylothorax includes evacuation of the pleural cavity through a chest tube to alleviate dyspnoea, and dietary fat restriction aimed at reducing lymph flow. When these measures fail to control lymph flow, surgical interventions are employed to achieve definite closure of the thoracic duct leak. Several case reports and series have shown that octreotide is safe and probably effective in both children and adults with chylothorax of different origins. The property of somatostatin and octreotide to induce leak closure is attributed to a decelerating effect on lymph flow, although their exact mechanism of action is not well defined. In successful cases, a substantial reduction of lymph drainage through the chest tube is evident within the first few days of commencing the drug, and treatment lasts for 1-2 weeks. Treatment failure has been also reported, however. SUMMARY Accumulating evidence suggests that octreotide is a putative novel therapeutic intervention for chylothorax. It is imperative that randomized controlled studies are conducted in order to fully elucidate the efficacy and safety of this treatment.
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Affiliation(s)
- Ioannis Kalomenidis
- Department of Critical Care and Pulmonary Services, Athens Medical School, Evangelismos Hospital, Athens, Greece.
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Evans JG, Spiess PE, Kamat AM, Wood CG, Hernandez M, Pettaway CA, Dinney CPN, Pisters LL. Chylous ascites after post-chemotherapy retroperitoneal lymph node dissection: review of the M. D. Anderson experience. J Urol 2006; 176:1463-7. [PMID: 16952661 DOI: 10.1016/j.juro.2006.06.016] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2005] [Indexed: 11/24/2022]
Abstract
PURPOSE We determined the clinical presentation, risk factors and optimal treatment of chylous ascites that develop after retroperitoneal lymph node dissection in patients with testicular cancer. MATERIALS AND METHODS We retrospectively reviewed the records of 329 patients who underwent post-chemotherapy retroperitoneal lymph node dissection at our institution, of whom 23 (7%) had chylous ascites postoperatively. Clinical and pathological parameters were entered into a database. RESULTS Mean patient age at chylous ascites presentation was 32.1 years. On univariate and multivariate logistic regression analyses increasing amounts of preoperative chemotherapy (OR 1.24) and intraoperative blood loss (OR 1.33) were predictive of chylous ascites. The clinical presentation of chylous ascites consisted of abdominal fullness and distention in all patients. Initial treatment was paracentesis alone or combined with total parenteral nutrition in 77% of patients. An abdominal drain was used for persistent ascites in 10 patients. In patients treated conservatively the rate of resolution of chylous ascites was 77%. Only 23% of patients required peritoneovenous shunt placement. However, shunt use was associated with an 80% surgical revision rate. CONCLUSIONS Conservative treatment resolves most cases of postoperative chylous ascites. An abdominal catheter drain should be considered for significant or recurring chylous ascites. When a peritoneovenous shunt is required, it may be needed for an extensive period for resolution and there are significant complications associated with its use. Increasing amounts of preoperative chemotherapy and operative blood loss raise the likelihood of chylous ascites.
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Affiliation(s)
- James G Evans
- Department of Urologic Oncology, University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA
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32
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Link RE, Amin N, Kavoussi LR. Chylous ascites following retroperitoneal lymphadenectomy for testes cancer. ACTA ACUST UNITED AC 2006; 3:226-32; quiz 233. [PMID: 16607371 DOI: 10.1038/ncpuro0457] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2005] [Accepted: 02/21/2006] [Indexed: 11/08/2022]
Abstract
BACKGROUND A 31-year-old man underwent a radical orchiectomy for a stage I mixed germ-cell tumor with angiolymphatic invasion. A subsequent laparoscopic retroperitoneal lymphadenectomy was complicated by a laceration to the aorta at the ostia of the more inferior of two right renal arteries. This was repaired following conversion to an open laparotomy. The patient presented 14 days later with genital swelling and increasing abdominal girth. INVESTIGATIONS Physical examination, abdominal and pelvic CT, laboratory albumin testing, lymphoscintogram and lymphangiogram. DIAGNOSIS Chylous ascites with tracking of lymphatic fluid into the left groin through a defect in the internal inguinal ring. MANAGEMENT Conservative management with salt restriction, a medium-chain fatty-acid diet and diuretics; exploratory laparoscopy, during which a small left inguinal hernia was repaired and chylous fluid was drained. Following further leakage, the patient was placed on total parenteral nutrition, followed by image-guided sclerotherapy with doxycycline.
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Affiliation(s)
- Richard E Link
- Division of Endourology and Minimally-Invasive Surgery, Scott Department of Urology at Baylor College of Medicine, Houston, TX 77030, USA.
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