Chylous ascites following para-aortic lymphadenectomy: a case report

Chylous ascites in laparoscopic renal surgery: Where do we stand?

Postoperative chylous ascites, which is caused by the disruption of lymphatic channels and persistent lymphatic leakage, was a rare complication in the urologic field before laparoscopic surgery was introduced. Now that laparoscopic urologic surgery, especially laparoscopic nephrectomy, is widely performed, chylous ascites as a complication of laparoscopic renal surgery has been reported more frequently. With these accumulated experiences and data comes knowledge about the proper diagnosis and management of chylous ascites, although there is still some debate regarding the correct protocol for diagnosis and management. Therefore, we performed a systematic review of the current literature regarding the etiology, incidence, diagnosis, management, and prognosis of chylous ascites after laparoscopic renal surgery, as well as strategies used to prevent it, and discuss current perspectives on overcoming this complication in the laparoscopic age.

Octreotide therapy for the management of refractory chylous ascites after a staging operation for endometrial adenocarcinoma

Chylous ascites after para-aortic lymphadenectomy is caused by a rupture in the retroperitoneal lymphatic channels. The incidence of postoperative chylous ascites is increasing as para-aortic lymphadenectomy for the management of gynecologic malignancies becomes more common. However, management of this condition remains unsatisfactory because some patients do not respond to conservative methods and have to undergo surgical intervention, even though they may be malnourished and immunosuppressed. We report the case of a patient who underwent a standard staging operation for endometrial cancer and experienced a large amount of lymphatic leakage, in spite of treatment with total parenteral nutrition and a low-fat diet for over 40 days. As a step-up approach, octreotide, a somatostatin analog, was added and the disease resolved completely. This case demonstrated that octreotide therapy is highly effective in refractory cases of chylous ascites where a large amount of leakage is observed and cases that are otherwise indicated for surgical intervention.

Chylous ascites: analysis of 24 patients

OBJECTIVES

Chylous ascites is the pathologic accumulation of lymphatic fluid in the peritoneal cavity. Patients who underwent surgery for gynecologic malignancy and had postoperative chylous ascites were evaluated retrospectively.

METHODS

We reviewed 1514 patients who had staging surgery for gynecologic malignancy at our institution from January 2003 to February 2012. We analyze the patients who develop chylous ascites and who didn't.

RESULTS

Twenty-four (2%) patients had postoperative chylous ascites. In the patients with chylous ascites, the median number of removed para-aortic lymph nodes was 26 (range 8-54), while this number was 17 (range 1-76) for the patients who didn't develop chylous ascites (p=0.001). Among the patients with chylous ascites, nine patients took chylous diet and 15 patients took TPN as the initial treatment. Totally seven (29%) patients required surgical correction, since 17 (71%) responded to conservative treatment. In the TPN group, the time from staging surgery to the diagnosis of chylous ascites was significantly longer in the group who required surgery compared with the group who did not (20 days vs 8 days, p:0.037). In addition this time wasn't statistically different from the patients' time in the diet group who didn't require surgery.

CONCLUSION

The aggressiveness of para-aortic lymphadenectomy should be individualized and the lymphatics should be controlled with suture ligation or hemoclips, since the extent and method of para-aortic lymphadenectomy has a determinative role in the development of chylous ascites. It may be logical to treat chylous ascites with diet rather than TPN initially in case the symptoms occur later.

The conservative treatment of postoperative chylous ascites in gynecologic cancers: four case reports

INTRODUCTION

Chylous ascites is a rare complication following radical surgery in gynecologic cancers. Its treatment is difficult due to nutritional and immunological problems caused by protein and lymphocyte loss. Its conservative treatment includes the use of a low-fat diet, medium chain triglyceride intake, paracentesis, total parenteral nutrition, and somatostatins. Other treatment options for resistant cases include surgical exploration and peritoneovenous shunt.

CASE REPORT

We present four gynecologic cancer cases with development of chylous ascites following pelvic-para-aortic lymph dissection. Two of these cases were endometrial cancer, one was cervical cancer, and the last one was ovarian cancer. In three of these cases, chylous ascites developed immediately after surgery. In the cervical cancer case, it developed following surgery and radiotherapy. All subjects responded to conservative treatment.

CONCLUSION

Chylous ascites should be considered in the differential diagnosis of abdominal distension following retroperitoneal surgery. Cases generally respond well to conservative treatment. However, treatment options should be personalized, and the right treatment should be chosen for each patient. The best measure is to pay utmost attention to the ligation of large lymph vessels during lymph dissection.

Chylous ascites in gynecologic malignancies: cases report and literature review

PURPOSE

Chylous ascites is an infrequent postoperative complication after retroperitoneal surgical procedure. Despite its infrequent occurrence, postoperative chylous ascites are associated with significant morbidity. Reports of chylous ascites or fistula after retroperitoneal lymph node dissection for gynecologic malignancies without radiation therapy are rare. A search in the English literature showed only 31 cases of chylous fistula for gynecologic malignancies. Treatment may be conservative with low-fat oral diet with medium-chain triglycerides associated or not to octreotide and total parenteral nutrition. In case of conservative measures failure, it can be managed by surgical intervention or peritoneo-venous shunt.

METHODS

We report two cases of chylous fistula following systematic pelvic and retroperitoneal lymph node dissection for gynecological cancer without radiotherapy and review the literature.

RESULTS

Both were successfully managed with the maintenance of the postoperative drain, total parenteral nutrition, octreotide and dietary intervention.

CONCLUSIONS

Chylous ascites should be included in differential diagnosis of abdominal distention after surgical retroperitoneal approach or radiotherapy. Most of the patients may have their chylous ascites successfully treated with conservative management. However, the best policy is to prevent chylous complications by employing meticulous dissection techniques and careful control of the major lymphatics by suture ligation during the primary surgical intervention.

Profound but dysfunctional lymphangiogenesis via vascular endothelial growth factor ligands from CD11b+ macrophages in advanced ovarian cancer

Severe ascites is a hallmark of advanced ovarian cancer (OVCA), yet the underlying mechanism that creates an imbalance between peritoneal vascular leakage and lymphatic drainage is unknown. Here, we identified and characterized peritoneal lymphatic vessels in OVCA mice, a model generated by implantation of human OVCA cells into athymic nude mice. The OVCA mice displayed substantial lymphangiogenesis and lymphatic remodeling, massive infiltration of CD11b(+)/LYVE-1(+) macrophages and disseminated carcinomatosis in the mesentery and diaphragm, and progressive chylous ascites formation. Functional assays indicated that the abnormally abundant lymphatic vessels in the diaphragm were not conductive in peritoneal fluid drainage. Moreover, lipid absorbed from the gut leaked out from the aberrant mesenteric lymphatic vessels. Our results indicate that vascular endothelial growth factor (VEGF)-C, VEGF-D, and VEGF-A from CD11b(+) macrophages are responsible for producing OVCA-induced dysfunctional lymphangiogenesis, although other cell types contribute to the increased ascites formation. Accordingly, the combined blockade of VEGF-C/D and VEGF-A signaling with soluble VEGF receptor-3 and VEGF-Trap, respectively, markedly inhibited chylous ascites formation. These findings provide additional therapeutic targets to ameliorate chylous ascites formation in patients with advanced OVCA.

Cisterna chyli: A detailed anatomic investigation

With recent laparoscopic advancements in retroperitoneal and thoracic surgical procedures, familiarity with major lymphatic structures, such as including the cisterna chyli (CC) and thoracic duct (TD), has proven beneficial in avoiding misdiagnosis and iatrogenic intraoperative injury. In this light, the aim of our study was to explore and delineate the topography of the CC, classify the different patterns of lymphatic tributaries, and categorize its varying location with respect to the vertebral bodies. The anatomy of the CC was examined in 120 adult human cadavers. The CC was found in 83.3% of the specimens and both the tributaries of the CC and the location, with respect to vertebral level, demonstrated wide variation. The results were classified into four types. The most common tributary configuration (type I), found in 45% specimens, was a single CC formed by the union of the left lumbar trunk (LT) and the intestinal trunk (IT). In 30% the CC was formed where the IT opened into the TD and the right lumbar trunk (RT), LT, retroaortic nodes (RN) and branches from the intercostal lymphatics (IL) joined variably (type II). In 20% the CC was formed by the junction of the RT and IT (type III), while in 5% there was a variable confluence pattern of lymphatic trunks that could not be classified (type IV). The CC was located at L1-L2 (type A) in 63%, T12-L1 (type B) in 21%, T11-T12 (type C) in 8%, T10-11 (type D) in 5%, and T9-10 (Type E) in 3%, of the specimens. The CC was found in the retrocrural space and, in 75% of the cases, to the right of the abdominal aorta. We hope that the data supplied by this study will provide useful information in the future to anatomists, radiologists and surgeons alike.

Bevacizumab combination therapy in recurrent, platinum-refractory, epithelial ovarian carcinoma: A retrospective analysis

BACKGROUND

The study was undertaken to determine the safety and efficacy of the monoclonal, antivascular endothelial growth factor antibody bevacizumab in combination with cytotoxic chemotherapy for women with platinum-refractory ovarian cancer.

METHODS

A retrospective analysis of women who received bevacizumab in combination with a cytotoxic agent was performed. Response was determined by measurable disease or assessment of serial cancer antigen (CA) 125 measurements.

RESULTS

Twenty-three patients were identified. The patients were heavily pretreated with a median of 7 prior regimens including a median of 3 prior platinum regimens. The combination regimen included cyclophosphamide in 15 (65%), 5-fluorouracil (5-FU) in 6 (26%), docetaxel in 1 (4%), and gemcitibine/liposomal doxorubicin in 1 (4%). Two (9%) women developed chylous ascites during treatment. CTC Grade 4-5 toxicities occurred in 4 (17%) subjects. Gastrointestinal perforation occurred in 2 (9%) patients. Measurable disease was present in 22. The overall best response rate was 35% and all 8 were partial responses (PRs). Stable disease was found in a further 10 (44%) women, whereas progressive disease was observed in 5 (22%). The median time to progression was 5.6 months in patients with a PR and 2.3 months in subjects with stable disease. Three (13%) women experienced a progression-free interval (PFI) of >6 months. At last follow-up, 8 (35%) subjects had died of disease, whereas 15 (65%) women were alive with disease.

CONCLUSIONS

Combination bevacizumab therapy demonstrated activity in heavily pretreated women with ovarian cancer. Gastrointestinal perforations were identified in 9%. Despite the toxicity of the regimen, prospective studies, particularly in less heavily pretreated patients, are warranted.

Chylous ascites as a complication of laparoscopic donor nephrectomy

Laparoscopic living donor nephrectomy (LLDN) is a minimally invasive technique for kidney procurement and was developed with the hope of reducing the disincentives associated with live renal donation. Compared with open donor nephrectomy (ODN), this alternative has many advantages including less postoperative pain and earlier return to work. Unfortunately, these benefits are sometimes negated by postoperative complications. Among these, chylous ascites (CA) is a rare but serious problem that is usually managed conservatively. We report the case of a living donor who developed CA refractory to initial conservative management and surgical treatment. We also discuss the role of surgery in the treatment of CA following LLDN.

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

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