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Zahradnikova P, Pechanova R, Fedorova L, Jager R, Nedomova B, Babala J. Laparoscopic management of the congenital chylous ascites in a newborn: Case report. J Minim Access Surg 2023; 19:548-551. [PMID: 37282439 PMCID: PMC10695317 DOI: 10.4103/jmas.jmas_304_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 01/06/2023] [Accepted: 01/27/2023] [Indexed: 06/08/2023] Open
Abstract
Congenital chylous ascites (CCA) is a rare condition seen in the neonatal period. The pathogenesis is primarily related to congenital intestinal lymphangiectasis. Conservative treatment of chylous ascites involves paracentesis, total parenteral nutrition (TPN), medium-chain triglyceride (MCT)-based milk formula, use of somatostatin analogue and octreotide. Surgical treatment is considered when conservative treatment fails. We describe a laparoscopic treatment of CCA using the fibrin glue technique. A male infant, in whom foetal ascites was detected at 19 weeks of gestation, was born by caesarean section at 35 weeks of gestation weighing 3760 g. There was evidence of hydrops in the foetal scan. A diagnosis of chylous ascites was made by abdominal paracentesis. A magnetic resonance scan was suggestive of gross ascites, and no lymphatic malformation was identified. TPN and octreotide infusion was started and continued for 4 weeks, but the ascites persisted. The failure of conservative treatment led us to perform laparoscopic exploration. Intraoperatively, chylous ascites and multiple prominent lymphatic vessels around the root of the mesentery were noted. The fibrin glue was applied over the leaking mesenteric lymphatic vessels in the duodenopancreatic region. Oral feeding was started from post-operative day 7. After 2 weeks of the MCT formula, ascites progressed. Thus, laparoscopic exploration was necessary. We introduced an endoscopic applicator for fibrin glue and applied it into the place of leakage. The patient was doing well with no appearance of ascites reaccumulating and was discharged on the 45th post-operative day. Follow-up ultrasonography (1st, 3rd and 9th months after discharge) showed a small amount of ascitic fluid but with no clinical significance. Laparoscopic localisation and ligation of leakage sites could be difficult, especially in newborns and young infants due to the small size of lymphatic vessels. The use of fibrin glue to seal the lymphatic vessels is quite promising.
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Affiliation(s)
- Petra Zahradnikova
- Department of Paediatric Surgery, Faculty of Medicine, Comenius University in Bratislava, National Institute of Children’s Diseases in Bratislava, Slovakia
| | - Rebeka Pechanova
- Department of Paediatric Surgery, Faculty of Medicine, Comenius University in Bratislava, National Institute of Children’s Diseases in Bratislava, Slovakia
| | - Lenka Fedorova
- Department of Paediatric Surgery, Faculty of Medicine, Comenius University in Bratislava, National Institute of Children’s Diseases in Bratislava, Slovakia
| | - Rene Jager
- Department of Paediatric Surgery, Faculty of Medicine, Comenius University in Bratislava, National Institute of Children’s Diseases in Bratislava, Slovakia
| | - Barbora Nedomova
- Department of Paediatric Anaesthesiology and Intensive Medicine, Faculty of Medicine, Comenius University in Bratislava, National Institute of Children’s Diseases in Bratislava, Slovakia
| | - Jozef Babala
- Department of Paediatric Surgery, Faculty of Medicine, Comenius University in Bratislava, National Institute of Children’s Diseases in Bratislava, Slovakia
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Nakano TA, Dori Y, Gumer L, Liptzin DR, Hill LRS, Kulungowski AM. How we approach pediatric congenital chylous effusions and ascites. Pediatr Blood Cancer 2022; 69 Suppl 3:e29246. [PMID: 36070215 DOI: 10.1002/pbc.29246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 06/19/2021] [Accepted: 06/27/2021] [Indexed: 11/10/2022]
Abstract
Congenital lymphatic leak may develop in patients with maldeveloped lymphatics and result in life-threatening fluid and electrolyte imbalance, protein deficiency, and immunodeficiency. Rapid diagnosis and therapy are necessary to prevent these complications; however, the field lacks clinical trials to support standardized diagnostic treatment guidelines. We present our current multidisciplinary approach to the diagnosis and management of congenital lymphatic leak including chylous pleural effusions and ascites. Depending on the rate of lymphatic leak, therapy can range from observation with nutritional modifications to surgical and interventional procedures aimed to reduce lymphatic drainage. Modalities to image central and peripheral lymphatics have advanced considerably. Genetic variants and subsequent targets that drive lymphatic maldevelopment have expanded the repertoire of possible pharmacotherapeutic options.
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Affiliation(s)
- Taizo A Nakano
- Vascular Anomalies Center, Children's Hospital Colorado, Aurora, Colorado, USA.,Center for Cancer and Blood Disorders, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Yoav Dori
- Division of Cariology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Lindsey Gumer
- Division of Pediatric Gastroenterology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Deborah R Liptzin
- Breathing Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Lauren R S Hill
- Vascular Anomalies Center, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Ann M Kulungowski
- Vascular Anomalies Center, Children's Hospital Colorado, Aurora, Colorado, USA.,Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
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3
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Necrotizing enterocolitis as a side effect of octreotide in a preterm neonate, a case report. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2021.102136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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4
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Sooklin L, Anand AJ, Rajadurai VS, Chandran S. Management of large congenital chylous ascites in a preterm infant: fetal and neonatal interventions. BMJ Case Rep 2020; 13:13/9/e235849. [PMID: 32878831 DOI: 10.1136/bcr-2020-235849] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Congenital chylous ascites is a rare cause of ascites in newborn infants. Its aetiology varies from localised leaky lymphatic duct to genetic syndromes. Most of these cases have transient ascites resolving over time with conservative management but some may progress needing medical as well as surgical treatment. We describe a case of antenatally detected large fetal ascites necessitating abdominal paracentesis and amnioreduction. Marked respiratory distress at birth required urgent abdominal paracentesis to relieve symptoms. The infant initially showed a good response to medium chain triglyceride (MCT) based formula milk feeds. Feeds were discontinued for 3 weeks due to sepsis with ileus. On recovery, recommencement of feeds resulted in reaccumulation of ascites. As the response to MCT-based formula was inadequate, octreotide therapy was initiated. Ascites showed remarkable resolution over the next 2 weeks and was discharged home. Follow-up at 5 years of age revealed normal growth and neurodevelopment.
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Affiliation(s)
- Loo Sooklin
- Neonatology, KK Women's and Children's Hospital, Singapore
| | - Amudha Jayanthi Anand
- Neonatology, KK Women's and Children's Hospital, Singapore.,Paediatrics, Lee Kong Chian School of Medicine, Singapore.,Paediatrics, Yong Loo Lin School of Medicine, Singapore.,Paediatrics, Duke NUS Medical School, Singapore
| | - Victor Samuel Rajadurai
- Neonatology, KK Women's and Children's Hospital, Singapore.,Paediatrics, Lee Kong Chian School of Medicine, Singapore.,Paediatrics, Yong Loo Lin School of Medicine, Singapore.,Paediatrics, Duke NUS Medical School, Singapore
| | - Suresh Chandran
- Neonatology, KK Women's and Children's Hospital, Singapore .,Paediatrics, Lee Kong Chian School of Medicine, Singapore.,Paediatrics, Yong Loo Lin School of Medicine, Singapore.,Paediatrics, Duke NUS Medical School, Singapore
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5
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Carr BD, Grant CN, Overman RE, Gadepalli SK, Geiger JD. Retroperitoneal exploration with Vicryl mesh and fibrin tissue sealant for refractory chylous ascites. J Pediatr Surg 2019; 54:604-607. [PMID: 30340876 DOI: 10.1016/j.jpedsurg.2018.09.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 09/18/2018] [Accepted: 09/25/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Congenital chylous ascites poses a significant challenge in neonatal care, and often results in prolonged, complex hospital stays and increased mortality. Few effective options exist in refractory cases. METHODS Patients aged 0 to 12 months with refractory chylous ascites underwent retroperitoneal exploration after medical treatment and minimally invasive therapies were unsuccessful. The retroperitoneum was completely exposed via left and right medial visceral rotation and opening the lesser sac. Visible leaks were ligated, and alternating layers of fibrin glue and Vicryl mesh were used to cover the entire retroperitoneum. RESULTS All 4 patients had resolution of their chylous ascites. None required reoperation or reintervention for chyle leaks. All achieved goal enteral feeds at a median of 29 days postoperatively and were discharged from hospital at a median of 42 days postoperatively. CONCLUSIONS Management of chylous ascites is extremely challenging in refractory cases. Complete retroperitoneal exposure with fibrin glue and Vicryl mesh application offers a definitive, reliable therapy for achieving cessation of lymphatic leakage and ultimate recovery for patients who fail all nonoperative approaches. STUDY TYPE Therapeutic. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Benjamin D Carr
- Department of Surgery, Division of Pediatric Surgery, University of Michigan, 1540 E Hospital Dr. SPC 4217, Ann Arbor, MI 48109, United States.
| | - Christa N Grant
- Department of Surgery, Division of Pediatric Surgery, University of Michigan, 1540 E Hospital Dr. SPC 4217, Ann Arbor, MI 48109, United States.
| | - Richard E Overman
- Department of Surgery, Division of Pediatric Surgery, University of Michigan, 1540 E Hospital Dr. SPC 4217, Ann Arbor, MI 48109, United States.
| | - Samir K Gadepalli
- Department of Surgery, Division of Pediatric Surgery, University of Michigan, 1540 E Hospital Dr. SPC 4217, Ann Arbor, MI 48109, United States.
| | - James D Geiger
- Department of Surgery, Division of Pediatric Surgery, University of Michigan, 1540 E Hospital Dr. SPC 4217, Ann Arbor, MI 48109, United States.
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Liu J, Zhang H, Du Q, Yao S. Successful Laparoscopic Treatment of Chylous Ascites after Pelvic Lymphadenectomy: A Case Report and Peanut Oil Application. J Minim Invasive Gynecol 2018; 25:923-926. [DOI: 10.1016/j.jmig.2017.12.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 12/24/2017] [Accepted: 12/28/2017] [Indexed: 01/03/2023]
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8
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Zalles-Vidal CR, Peñarrieta-Daher A, Ibarra-Rios D, Fernandez-Portilla E, Bracho-Blachet E. Chylous Ascites in a Newborn with Gastroschisis. Case Report. J Neonatal Surg 2017; 6:16. [PMID: 28083502 PMCID: PMC5224749 DOI: 10.21699/jns.v6i1.428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 10/19/2016] [Indexed: 11/11/2022] Open
Abstract
Chylous ascites is a rare disease, only two cases associated with gastroschisis have been published. We report a case treated conservatively with total parenteral nutrition (TPN) and octreotide. We reviewed the literature about management options for the chylous ascites.
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Affiliation(s)
- Cristian Ruben Zalles-Vidal
- Department of Pediatric Surgery (Neonatal Surgery Service), Hospital Infantil de México Federico Gomez, México City
| | - Alejandro Peñarrieta-Daher
- Department of Pediatric Surgery (Neonatal Surgery Service), Hospital Infantil de México Federico Gomez, México City
| | - Daniel Ibarra-Rios
- Department of Neonatology, Hospital Infantil de México Federico Gomez, México City
| | - Emilio Fernandez-Portilla
- Department of Pediatric Surgery (Neonatal Surgery Service), Hospital Infantil de México Federico Gomez, México City
| | - Eduardo Bracho-Blachet
- Department of Pediatric Surgery (Neonatal Surgery Service), Hospital Infantil de México Federico Gomez, México City
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9
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Abstract
Leakage of lymph from the lymphatic ducts causes chylothorax (CT) or chylous ascitis (CA). This may happen for unknown reasons during fetal life or after birth and may also be caused by trauma after thoracic surgery or by other conditions. Fetal CT and CA may be lethal particularly in cases with fetal hydrops that sometimes benefit of intra-uterine instrumentation. After birth, symptoms are related to the amount of accumulated fluid. Sometimes, severe cardio-respiratory compromise prompts active therapy. Most patients with CT or CA benefit from observation, rest, and supportive measures alone. Drainage of the fluid may be necessary, but then loss of protein, fat, and lymphoid cells introduce new risks and require careful replacement. Low-fat diets with MCT and parenteral nutrition decrease fluid production while allowing adequate nutritional input. If lymph leakage does not stop, secretion inhibitors like somatostatin or octreotide are prescribed, although there is only weak evidence of their benefits. Imaging of the lymphatic system is indicated when the leaks persist, but this is technically demanding in children. Shunting of the lymph from one body space to another by means of valved catheters, embolization of the thoracic duct, and/or ligation of the major lymphatics may occasionally be indicated in cases refractory to all other treatments.
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Affiliation(s)
- Juan C Lopez-Gutierrez
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain; Department of Pediatrics, Universidad Autonoma de Madrid, Madrid, Spain
| | - Juan A Tovar
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain; Department of Pediatrics, Universidad Autonoma de Madrid, Madrid, Spain.
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10
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Moreira DDAR, Santos MM, Tannuri ACA, Tannuri U. Congenital chylous ascites: a report of a case treated with hemostatic cellulose and fibrin glue. J Pediatr Surg 2013; 48:e17-9. [PMID: 23414895 DOI: 10.1016/j.jpedsurg.2012.11.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2012] [Revised: 11/14/2012] [Accepted: 11/15/2012] [Indexed: 10/27/2022]
Abstract
We report a case of an infant with recurrent chylous ascites who was unresponsive to conventional medical treatment. An exploratory laparotomy revealed no macroscopically visible sites of lymph leakage that could be ligated. Lymph exudation was noted in areas near the subhepatic recess and in the lesser sac surrounding the pancreas, which was not amenable to suture. The treatment consisted of the placement of a hemostatic mesh composed of oxidized cellulose (Surgicel) on these areas, with a thin layer of fibrinogen/thrombin glue over the mesh (Tissucol). The cellulose mesh allowed for greater adhesion of the fibrin glue to the diseased tissues. The patient had no recurrence of ascites and is currently 20 months old, with good weight-height gain, and free of ascites.
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Affiliation(s)
- Daniel de Albuquerque Rangel Moreira
- Pediatric Surgery Division, Pediatric Liver Transplantation Unit, Laboratory of Research in Pediatric Surgery (LIM 30), University of Sao Paulo Medical School, Sao Paulo, Brazil
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11
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What is the result: chylous leakage following extensive radical surgery of neuroblastoma. World J Pediatr 2012; 8:151-5. [PMID: 21633857 DOI: 10.1007/s12519-011-0296-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2010] [Accepted: 12/21/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Postoperative chylous leakage is a rare complication that results from disruption of either mediastinal or retroperitoneal lymphatic channels during dissection or from obstruction by original lesions such as a malignancy. There is lack of clinical experience in pediatric patients about how to manage the leakage and what the result will be. METHODS We retrospectively analyzed the clinical outcomes of 5 children with neuroblastoma (NB) (stage 4 in 4 children and stage 1-2 in 1 child) who had received non-surgical treatment of chylothorax and/or chylous ascites after retroperitoneal/posterior mediastinal extensive radical resection of NB for complete tumor removal. Conservative therapy with low-fat diet, medium-chain triglyceride and/or total parenteral nutrition was the mainstay treatment for chylous leakage. RESULTS Four of the 5 children recovered after 6-32 days of conservative treatment, and the last one who did not respond was cured by surgical management for chylous fistula 45 days after primary surgery. Postoperative imaging showed that more than 90% of tumors were resected and all of them showed very good partial remission (VGPR). Among the 4 patients in stage 4, 3 relapsed after radical resection of NB. The patient of stage 1-2 was still in VGPR. CONCLUSIONS The majority of patients with chylous ascites/chylothorax after extensive radical surgery for posterior mediastinum/retroperitoneum NB could be cured by non-surgical treatment. But the final result of original disease has not been greatly changed by intensive surgery for stage 4 NB.
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12
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Abstract
PURPOSE The purpose of the present study was to evaluate the prognostic factors and review the outcome of primary isolated fetal ascites. METHODS A retrospective cohort study was conducted for fetuses with primary isolated ascites with a prenatal diagnosis between 1994 and 2009. The patients were divided into the favorable group (Group I) whose ascites were resolved by medical treatment alone and an unfavorable group (Group II) who required surgical intervention after birth due to refractory ascites. RESULTS There were seven patients in Group I and five patients in Group II. Six of seven patients who developed ascites after 30 weeks' gestation were categorized in Group I, and four of five infants who developed ascites before 30 weeks' gestation were categorized in Group II. There was a negative correlation between the gestational age at diagnosis and the severity of the fetal abdominal distention. In Group II, the ascites resolved in two cases and was reaccommodated in another two cases after surgery. An infant with trisomy 21 received continuous drainage and eventually died of infection. CONCLUSIONS The prognosis of primary isolated fetal ascites can be predicted based on the gestational age at diagnosis and the severity of the fetal abdominal distention.
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13
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Spagnol L, Conforti A, Valfrè L, Morini F, Bagolan P. Preoperative administration of Sudan III and successful treatment of persistent chylous ascites in a neonate. J Pediatr Surg 2011; 46:994-7. [PMID: 21616268 DOI: 10.1016/j.jpedsurg.2011.01.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Revised: 01/07/2011] [Accepted: 01/10/2011] [Indexed: 11/20/2022]
Abstract
Congenital chylous ascites is a rare entity, and surgical treatment is confined to selected intractable cases. We report 2 cases of refractory congenital chylous ascites successfully treated with preoperative administration of lipophilic dye (Sudan III) followed by abdominal systematic surgical exploration, cauterization, and fibrin glue application.
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Affiliation(s)
- Lorna Spagnol
- Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Bambino Gesù Children's Research Hospital, 00165 Rome, Italy
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14
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Steinemann DC, Dindo D, Clavien PA, Nocito A. Atraumatic chylous ascites: systematic review on symptoms and causes. J Am Coll Surg 2011; 212:899-905.e1-4. [PMID: 21398159 DOI: 10.1016/j.jamcollsurg.2011.01.010] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Revised: 01/10/2011] [Accepted: 01/11/2011] [Indexed: 12/14/2022]
Affiliation(s)
- Daniel C Steinemann
- Department of Visceral and Transplantation Surgery, University Hospital Zurich, Zurich, Switzerland
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15
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Nau P, Narula V, Needleman B. Successful management of chyloperitoneum after laparoscopic adjustable gastric banding in 2 patients. Surg Obes Relat Dis 2011; 7:122-3. [DOI: 10.1016/j.soard.2010.02.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2010] [Revised: 02/03/2010] [Accepted: 02/05/2010] [Indexed: 10/19/2022]
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Melo-Filho AA, Souza IJN, Leite CAC, Leite RD, Colares JHF, Correia JMS. Refractory congenital chylous ascites. Indian J Pediatr 2010; 77:1335-7. [PMID: 20821276 DOI: 10.1007/s12098-010-0193-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Accepted: 08/19/2010] [Indexed: 10/19/2022]
Abstract
Refractory congenital chylous ascites (CCA) is an uncommon clinical condition. Few cases have been described and no gold standard treatment has been defined so far. This report describes a case of refractory CCA in a newborn child which was treated by surgery. Preoperative lower-limb lymphoscintigraphy associated with intraoperative patent blue testing and fibrin glue application were useful in order to provide a successful outcome.
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Affiliation(s)
- Antônio Aldo Melo-Filho
- Department of Surgery, Medical School, Federal University of Ceará (UFC), Rua Professor Costa Mendes, 1608, 3° andar, Rodolfo Teófilo, CEP: 60430-140, Fortaleza, Ceará, Brazil.
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Karagol BS, Zenciroglu A, Gokce S, Kundak AA, Ipek MS. Therapeutic management of neonatal chylous ascites: report of a case and review of the literature. Acta Paediatr 2010; 99:1307-10. [PMID: 20377539 DOI: 10.1111/j.1651-2227.2010.01818.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
UNLABELLED Congenital chylous ascites is a rare condition seen in the neonatal period and the data on pathogenesis and treatment modalities are limited. In this article, we report a case of neonate with chylous ascites and review the therapeutic management procedures on chylous ascites in childhood. We present our experience in the diagnosis and treatment of this condition. CONCLUSION Medium-chain triglycerides (MCT)-based diet can be tried as a first option in chylous ascites treatment. In resistant or unresponsive cases, somatostatin along with TPN can have use in closing the lymphatic leakage or relieving the symptoms effectively and rapidly. Conventional regimens including enteral feeding with MCT-based formula can then be re-administered as a maintenance treatment after reduction of lymph flow with the use of total parenteral nutrition (TPN) and somatostatin infusion combination. Patient-specific approach should be attempted for chylous ascites caused by various disorders and started as soon as possible.
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Affiliation(s)
- Belma Saygili Karagol
- Sami Ulus Maternity, Childrens' Education and Research Hospital, Division of Neonatology, Ankara, Turkey.
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18
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Abstract
The purpose of this retrospective review of the charts of 6 children who underwent surgical treatment of chylous ascites refractory to conservative measures between 1993 and 2006 was to evaluate the efficiency of fibrin glue application for control of lymph leakage. Five children had postoperative chylous ascites (neuroblastoma, 4; cystic lymphangioma, 1) and 1 had a congenital malformation. Surgical exploration revealed large areas of diffuse lymphatic leakage in all of the patients. Lymphatic fistula was not identified intraoperatively in any patient. Ingestion of lipophilic dye in a concentrated fatty meal was not helpful in locating a lymph fistula. Absorbable mesh was used in association with glue application in the last 3 patients treated. Control of ascites was achieved immediately in 2 patients and within 3 weeks in 2 patients. Repeat surgery was required in the remaining 2 patients. The mean follow-up time was 4.3 years. One patient died of tumor recurrence 12 months after surgical treatment without relapse of the ascites. Two mild late recurrences were observed at 6 and 11 months after surgery and were managed conservatively. The findings of this study show that fibrin glue application on absorbable mesh after dissection of the leakage zones is easy, safe, and effective. We recommend that surgery with glue application be repeated until control of ascites is achieved. We suggest fibrin glue application as a preventive measure against postoperative chylous ascites.
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Kuroiwa M, Toki F, Suzuki M, Suzuki N. Successful laparoscopic ligation of the lymphatic trunk for refractory chylous ascites. J Pediatr Surg 2007; 42:E15-8. [PMID: 17502170 DOI: 10.1016/j.jpedsurg.2007.02.036] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
A 3-year-old girl with recurrent chylous ascites was successfully treated by laparoscopic ligation of the ruptured lymphatic trunk. She was referred to our hospital at 16 days of age because of marked abdominal distension. Imaging methods showed massive ascites of unknown origin, and analysis of the ascites revealed its chylous nature. Conservative treatments were started. Her condition improved to some extent, and she was discharged. Two years later, she was readmitted with abdominal distension and loss of appetite. Laparoscopic surgery was planned to clarify the etiology and to treat intractable ascites. Sudan black B was orally administered, and laparoscopy revealed the presence of a whitish-gray fluid in the abdominal cavity, and a dark-blue stream of the dye was noticed. The responsible lesion of the chylous ascites was detected by tracking the stream. The lesion was ligated twice with an endoloop. She has been completely free from the symptoms for 3 years and 9 months. This experience indicates the usefulness of laparoscopic surgery in investigating the etiology of chylous ascites and treating it. The concomitant use of a lipophilic dye is mandatory to find the responsible lesion at surgery. Laparoscopic surgery, instead of open surgery, should be considered as a treatment of choice for intractable chylous ascites.
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Affiliation(s)
- Minoru Kuroiwa
- Department of Surgery, Gunma Children's Medical Center, Shibukawa, Gunma 377-8577, Japan.
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Chéreau E, Lejeune V, Gonzales M, Carbonne B. Voluminous fetal chylous ascites: a case of complete spontaneous prenatal regression. Fetal Diagn Ther 2006; 22:81-4. [PMID: 17135749 DOI: 10.1159/000097101] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2005] [Accepted: 03/28/2006] [Indexed: 11/19/2022]
Abstract
We report a case of isolated voluminous fetal ascites discovered during a routine fetal ultrasound at 22 weeks' gestation. Analysis of the fluid showed it to be chyliform and ruled out other causes of fetal ascites. Regular bimonthly ultrasound scans monitored its progressive diminution and then its disappearance. Examination showed the child to be normal at birth. Though the literature indicates that prognosis is usually favorable for infants with isolated fetal chylous ascites, spontaneous regression during pregnancy is an uncommon finding.
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Affiliation(s)
- Elisabeth Chéreau
- Department of Obstetrics and Gynecology, Hôpital Saint Antoine, Paris, France
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Campisi C, Bellini C, Eretta C, Zilli A, da Rin E, Davini D, Bonioli E, Boccardo F. Diagnosis and management of primary chylous ascites. J Vasc Surg 2006; 43:1244-8. [PMID: 16765248 DOI: 10.1016/j.jvs.2005.11.064] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2005] [Accepted: 11/21/2005] [Indexed: 12/23/2022]
Abstract
BACKGROUND Chylous ascites is the accumulation of triglyceride-rich, free, milk-like peritoneal fluid caused by the presence of intestinal lymph in the abdominal cavity. Primary chylous ascites is uncommon. We present our experience in the diagnosis and treatment of this condition. METHODS Twelve patients (7 adults, 5 children) affected by primary chylous ascites were studied. Diagnostic investigations included abdominal sonography scans, lymphoscintigraphy, and lymphography combined with computed tomography (CT) with intravenous and intralymphatic lipid-soluble contrast, and laparoscopy. Magnetic resonance imaging was used when lymphography and lymphatic CT were not able to define the dysplasia well, or in the presence of lymphatic dilatation. Surgical treatment included laparoscopy (12/12), drainage of ascites (12/12), the search for and treatment of abdominal and retroperitoneal chylous leaks (12/12), exeresis of lymphodysplastic tissues (12/12), ligation of incompetent lymph vessels (9/12), carbon dioxide laser treatment (cut and welding effects) of the dilated lymph vessels using an operating microscope for magnification (9/12), and chylovenous and lymphovenous microsurgical shunts (7/12). RESULTS Eight patients did not have a relapse of the ascites, and three patients had a persistence of a small quantity of ascites with no protein imbalance. Postoperative lymphoscintigraphy in seven patients confirmed better lymph flow and less lymph reflux. Median follow-up was 5 years (range, 3 to 7 years). We observed early relapse of chylous ascites in only one case that required a peritoneal-jugular shunt and led to good outcome. CONCLUSION Primary chylous ascites is closely correlated to lymphatic-lymphonodal dysplasia that does not involve a single visceral district alone. Medical preoperative treatment played an essential role in the global management of this complex pathology. We demonstrated that the use of laparoscopy is remarkably advantageous for confirming diagnosis, for draining the ascites, and for evaluating the extension of the dysplasia. Our diagnostic work-up provided us with an exact diagnostic assessment and allowed us to plan a precise surgical approach.
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Affiliation(s)
- Corradino Campisi
- Department of Surgery, Lymphatic Surgery and Microsurgery Unit, S. Martino Hospital, University of Genoa, Genoa, Italy
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Caumartin Y, Pouliot F, Sabbagh R, Dujardin T. Chylous ascites as a complication of laparoscopic donor nephrectomy. Transpl Int 2006; 18:1378-81. [PMID: 16297058 DOI: 10.1111/j.1432-2277.2005.00219.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
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.
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Affiliation(s)
- Yves Caumartin
- Service d'Urologie, Centre Hospitalier Universitaire de Québec, pavillon Hôtel-Dieu de Québec, Université Laval, Québec, Canada
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23
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Santos Arrontes D, Páez Borda A, Valer López-Fando MP, Luján Galán M, Pascual Mateo C, Berenguer Sánchez A. [Chylous ascites as a complication of retroperitoneal lymphadenectomy]. GASTROENTEROLOGIA Y HEPATOLOGIA 2004; 27:150. [PMID: 14998466 DOI: 10.1016/s0210-5705(03)79111-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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24
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Abstract
Since the introduction of minimal access surgery to general surgeons in the 1980s, pediatric surgeons have been employing this innovative technology to perform surgery on children. Video technology and miniaturized instruments have brought the laboratory to the operating room; in many cases several small incisions are the only access necessary to perform complicated procedures that would otherwise require a large wound. Additional benefits of minimal access surgery may include reduced postoperative analgesic requirements, shortened length of stay, and faster resumption of normal activities. Increased operative costs offset some of these gains. The pediatric surgical community has embraced minimal access techniques for some operations; others remain controversial.
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Affiliation(s)
- Jeffrey L Zitsman
- Children's Hospital of New York Presbyterian, College of Physicians and Surgeons, Columbia University, New York, New York 10032, USA.
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