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Abokhozima A, Zidan MH, Abo Elmagd A, Alokl M, Altabbaa H, Al Sayed M, Selim A. Lymphatic Chyle Duct Injury and Identification During Laparoscopic Sleeve Gastrectomy Preventing Postoperative Chylous Ascites. Obes Surg 2024; 34:1995-2000. [PMID: 38589758 PMCID: PMC11031454 DOI: 10.1007/s11695-024-07215-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 04/10/2024]
Abstract
We present a case of intraoperative detection of an iatrogenic chyle duct injury during laparoscopic sleeve gastrectomy. The chyle duct injury was identified and managed by ligature, preventing postoperative chylous ascites.
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Affiliation(s)
- Ahmed Abokhozima
- Alexandria University, El-Shatby, 22 El-Guish Road, Alexandria, 21526, Alexandria, Egypt
- Ekbal Hospital, 10 Hassan Amin Street, Alexandria, Egypt
| | - Mohamed H Zidan
- Alexandria University, El-Shatby, 22 El-Guish Road, Alexandria, 21526, Alexandria, Egypt.
- Alexandria Main University Hospital, Al Mothaf, Al Mesallah Sharq, Al Attarin, Alexandria, 5372066, Egypt.
- Ekbal Hospital, 10 Hassan Amin Street, Alexandria, Egypt.
| | - Ahmed Abo Elmagd
- Alexandria University, El-Shatby, 22 El-Guish Road, Alexandria, 21526, Alexandria, Egypt
- Alexandria Main University Hospital, Al Mothaf, Al Mesallah Sharq, Al Attarin, Alexandria, 5372066, Egypt
- Ekbal Hospital, 10 Hassan Amin Street, Alexandria, Egypt
| | - Mohammed Alokl
- Alexandria University, El-Shatby, 22 El-Guish Road, Alexandria, 21526, Alexandria, Egypt
- Ekbal Hospital, 10 Hassan Amin Street, Alexandria, Egypt
| | - Hashem Altabbaa
- Alexandria University, El-Shatby, 22 El-Guish Road, Alexandria, 21526, Alexandria, Egypt
| | - Mohamed Al Sayed
- Alexandria University, El-Shatby, 22 El-Guish Road, Alexandria, 21526, Alexandria, Egypt
- Alexandria Main University Hospital, Al Mothaf, Al Mesallah Sharq, Al Attarin, Alexandria, 5372066, Egypt
| | - Aliaa Selim
- Alexandria University, El-Shatby, 22 El-Guish Road, Alexandria, 21526, Alexandria, Egypt
- Ekbal Hospital, 10 Hassan Amin Street, Alexandria, Egypt
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DiBattista JV, Odenwald MA, Te H. Successful Treatment of Refractory Chylous Ascites With Octreotide in a Patient With Decompensated Cirrhosis. ACG Case Rep J 2024; 11:e01322. [PMID: 38560017 PMCID: PMC10977527 DOI: 10.14309/crj.0000000000001322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/28/2024] [Indexed: 04/04/2024] Open
Abstract
Chylous ascites is a rare manifestation of decompensated cirrhosis that is associated with increased short-term mortality. Exclusion of other etiologies must be performed to allow for appropriate management, which itself can be a challenge in the setting of decompensated cirrhosis. We report a case of chylous ascites in a patient with decompensated cirrhosis that was successfully managed with octreotide before liver transplantation.
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Affiliation(s)
- Jacob V. DiBattista
- Section of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - Matthew A. Odenwald
- Section of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - Helen Te
- Section of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Chicago Medicine, Chicago, IL
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Wagenpfeil J, Hoß K, Henkel A, Kütting D, Luetkens JA, Feldmann G, Brossart P, Attenberger UI, Pieper CC. Interventional treatment of refractory non-traumatic chylous effusions in patients with lymphoproliferative disorders. Clin Exp Med 2024; 24:63. [PMID: 38554229 PMCID: PMC10981590 DOI: 10.1007/s10238-024-01312-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 02/28/2024] [Indexed: 04/01/2024]
Abstract
To report results of interventional treatment of refractory non-traumatic abdomino-thoracic chylous effusions in patients with lymphoproliferative disorders. 17 patients (10 male; mean age 66.7 years) with lymphoproliferative disorders suffered from non-traumatic chylous effusions (chylothorax n = 11, chylous ascites n = 3, combined abdomino-thoracic effusion n = 3) refractory to chemotherapy and conservative therapy. All underwent x-ray lymphangiography with iodized-oil to evaluate for and at the same time treat lymphatic abnormalities (leakage, chylo-lymphatic reflux with/without obstruction of central drainage). In patients with identifiable active leakage additional lymph-vessel embolization was performed. Resolution of effusions was deemed as clinical success. Lymphangiography showed reflux in 8/17 (47%), leakage in 2/17 (11.8%), combined leakage and reflux in 3/17 (17.6%), lymphatic obstruction in 2/17 (11.8%) and normal findings in 2/17 cases (11.8%). 12/17 patients (70.6%) were treated by lymphangiography alone; 5/17 (29.4%) with leakage received additional embolization (all technically successful). Effusions resolved in 15/17 cases (88.2%); 10/12 (83.3%) resolved after lymphangiography alone and in 5/5 patients (100%) after embolization. Time-to-resolution of leakage was significantly shorter after embolization (within one day in all cases) than lymphangiography (median 9 [range 4-30] days; p = 0.001). There was no recurrence of symptoms or post-interventional complications during follow-up (median 445 [40-1555] days). Interventional-radiological treatment of refractory, non-traumatic lymphoma-induced chylous effusions is safe and effective. Lymphangiography identifies lymphatic abnormalities in the majority of patients and leads to resolution of effusions in > 80% of cases. Active leakage is found in only a third of patients and can be managed by additional embolization.
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Affiliation(s)
- Julia Wagenpfeil
- Division for Minimally-Invasive Lymph Vessel Therapy, Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Bonn, Germany.
| | - Katharina Hoß
- Division for Minimally-Invasive Lymph Vessel Therapy, Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Bonn, Germany
| | - Andreas Henkel
- Division for Minimally-Invasive Lymph Vessel Therapy, Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Bonn, Germany
| | - Daniel Kütting
- Division for Minimally-Invasive Lymph Vessel Therapy, Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Bonn, Germany
| | - Julian Alexander Luetkens
- Division for Minimally-Invasive Lymph Vessel Therapy, Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Bonn, Germany
| | - Georg Feldmann
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Bonn, Germany
- Department of Internal Medicine III, University Hospital of Bonn, Bonn, Germany
| | - Peter Brossart
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Bonn, Germany
- Department of Internal Medicine III, University Hospital of Bonn, Bonn, Germany
| | - Ulrike Irmgard Attenberger
- Division for Minimally-Invasive Lymph Vessel Therapy, Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Bonn, Germany
| | - Claus Christian Pieper
- Division for Minimally-Invasive Lymph Vessel Therapy, Department of Diagnostic and Interventional Radiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), Bonn, Germany
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Amine S, Aziz S, Babty M, Jaafar F, Abdellatif K, Ahmed IA. Successful management of chylous ascite after removal of residual mass in non-seminomatous germ cell tumours following chemotherapy: A single-center experience and review of the literature. Int J Surg Case Rep 2024; 118:109502. [PMID: 38657515 DOI: 10.1016/j.ijscr.2024.109502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/02/2024] [Accepted: 03/07/2024] [Indexed: 04/26/2024] Open
Abstract
INTRODUCTION Chylous ascites is a rare but morbid condition following removal of residual mass in non-seminomatous germ cell tumours following chemotherapy. CASE PRESENTATION We hereby present the case of a 20-year-old man who had undergone RPLND with complete surgical excision. A lesion of the Cisterna chyli complicated the operation. The post-operative course was marked by the appearance of chylous ascites. The conservative management strategy for this complication was successful, but only after a month. CLINICAL DISCUSSION Chylous ascites is a rare but morbid condition following removal of residual mass in non-seminomatous germ cell tumours following chemotherapy. Conservative management based on a high-protein diet with fat restriction and medium-chain triglyceride supplementation, and somatostatine are usually successful. Surgery should be reserved for situations that are refractory to treatment. CONCLUSIONS We report our successful management and, we also analysed the different management protocols using our experience and review of the literature.
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Affiliation(s)
- Slaoui Amine
- Urology Department, Avicenne Hospital, University Hospital Center IBN SINA, University Mohammed V, Rabat, Morocco.
| | - Slaoui Aziz
- Gynaecology-Obstetrics and Endoscopy Department, Maternity Souissi, University Hospital Center IBN SINA, University Mohammed V, Rabat, Morocco
| | - Mouftah Babty
- Urology Department, Avicenne Hospital, University Hospital Center IBN SINA, University Mohammed V, Rabat, Morocco
| | - Fouimtizi Jaafar
- Urology Department, Avicenne Hospital, University Hospital Center IBN SINA, University Mohammed V, Rabat, Morocco
| | - Koutani Abdellatif
- Urology Department, Avicenne Hospital, University Hospital Center IBN SINA, University Mohammed V, Rabat, Morocco
| | - Iben Atyya Ahmed
- Urology Department, Avicenne Hospital, University Hospital Center IBN SINA, University Mohammed V, Rabat, Morocco
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Morgan K, Abboud M, Friedman B, Su LM. Repair of lymphoperitoneal fistulae for chylous ascites following robotic-assisted partial nephrectomy: Anatomic foundation for left-sided predominance following renal surgery. Urol Case Rep 2024; 53:102656. [PMID: 38261916 PMCID: PMC10797531 DOI: 10.1016/j.eucr.2024.102656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/06/2024] [Accepted: 01/07/2024] [Indexed: 01/25/2024] Open
Abstract
Chylous ascites (CA) is a rare complication following renal surgery. Here we present the case of a 28-year-old female who developed CA after a robotic left partial nephrectomy. After failing conservative management, she underwent successful robotic-assisted diagnostic laparoscopy and ligation of lymphoperitoneal fistulae. The higher incidence of CA after left versus right-sided renal surgery may be explained by the para-aortic drainage of the intestinal lymphatic channels. Surgical intervention should be considered when conservative management fails.
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Affiliation(s)
- Kevin Morgan
- University of Florida, Department of Urology, 1600 SW Archer Road, Room N202B, Gainesville, FL, 32610, USA
| | - Marc Abboud
- University of Florida, Department of Urology, 1600 SW Archer Road, Room N202B, Gainesville, FL, 32610, USA
| | - Brett Friedman
- University of Florida, Department of Urology, 1600 SW Archer Road, Room N202B, Gainesville, FL, 32610, USA
| | - Li-Ming Su
- University of Florida, Department of Urology, 1600 SW Archer Road, Room N202B, Gainesville, FL, 32610, USA
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Chaichayanon S, Banjongjit A, Kanjanabuch T, Perl J. Chylous ascites: A warning sign of life-threatening encapsulated peritoneal sclerosis in patient recently transferred to haemodialysis. Perit Dial Int 2024; 44:149-151. [PMID: 37691434 DOI: 10.1177/08968608231193930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023] Open
Affiliation(s)
| | - Athiphat Banjongjit
- Nephrology unit, Department of Medicine, Vichaiyut Hospital, Bangkok, Thailand
| | - Talerngsak Kanjanabuch
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Kidney Metabolic Disorders, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Peritoneal Dialysis Excellent Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Jeffrey Perl
- Division of Nephrology and Keenan Research Center, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
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Tlili Y, Hadrich Z, Hafsi M, Sahir O, Rached B, Mestiri H. Refractory chylous ascites revealing follicular lymphoma: A case report. Int J Surg Case Rep 2024; 116:109414. [PMID: 38430893 PMCID: PMC10943983 DOI: 10.1016/j.ijscr.2024.109414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 02/14/2024] [Accepted: 02/16/2024] [Indexed: 03/05/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Chylous ascites is an uncommon form of ascites characterized by milky fluid rich in triglycerides. It is associated with poor lymphatic drainage. We report a case of chylous ascites revealing a follicular lymphoma. CASE PRESENTATION A 73-year-old man presented with a 6-month history of abdominal distension attributed to a chylous ascitis. The thoraco-abdomino-pelvic CT scan revealed voluminous intra- and retroperitoneal mass inseparable from the duodeno-pancreatic block and encompassing the mesenteric vessels, inferior vena cava and renal vessels; abundant ascites and multiple mediastinal, coeliomesenteric, retroperitoneal, iliac and inguinal adenomegalia. The diagnosis of follicular lymphoma was retained through a radio-guided biopsy of the retroperitoneal mass. The patient had weekly paracentesis and immuno-chemotherapy. The course was unfavorable, marked by infection of the ascites fluid after two cycles of immuno-chemotherapy. Our patient developed severe sepsis and died. CLINICAL DISCUSSION Chylous ascites in conjunction with follicular lymphoma is an exceptional presentation. The pathophysiological mechanism is an impediment to subdiaphragmatic lymphatic drainage caused by external pressure, leading to leakage of dilated subserosal lymphatic ducts into the peritoneal cavity. Histological confirmation is fundamental to manage chylous ascites resulting from lymphomas. CONCLUSION Chylous ascites revealing lymphoma is a unique condition. The key to management is the treatment of the underlying etiology.
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Affiliation(s)
- Yassine Tlili
- Department of General Surgery, Mongi Slim University Hospital, Faculty of Medicine of Tunis, Tunisia
| | - Zied Hadrich
- Department of General Surgery, Mongi Slim University Hospital, Faculty of Medicine of Tunis, Tunisia
| | - Montacer Hafsi
- Department of General Surgery, Mongi Slim University Hospital, Faculty of Medicine of Tunis, Tunisia.
| | - Omrani Sahir
- Department of General Surgery, Mongi Slim University Hospital, Faculty of Medicine of Tunis, Tunisia
| | - Bayar Rached
- Department of General Surgery, Mongi Slim University Hospital, Faculty of Medicine of Tunis, Tunisia
| | - Hafedh Mestiri
- Department of General Surgery, Mongi Slim University Hospital, Faculty of Medicine of Tunis, Tunisia
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Raitio A, Losty PD. Incidence and Risk Factors for Chyle Leaks After Neuroblastic Tumor Resection: A Systematic Review of Published Studies. J Pediatr Surg 2024:S0022-3468(24)00100-3. [PMID: 38490882 DOI: 10.1016/j.jpedsurg.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 02/12/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND Chyle leakage/ascites after surgical resection of neuroblastic tumors may delay the start of chemotherapy and worsen prognosis. Previous studies have reported a highly variable incidence and risk factors remain largely unknown. This study aims to analyze the true incidence of chyle leaks and ascites and seeks to identify risk factors and optimal treatment strategies. METHODS Medline/Embase databases were searched according to PRISMA guidelines. Literature reviews, case reports, and non-English papers were excluded. Data were extracted independently following paper selection by 2 authors. RESULTS The final analysis yielded 15 studies with N = 1468 patients. Chylous ascites was recorded postoperatively in 171 patients (12%). Most patients experiencing chyle leaks were successfully treated conservatively with drainage, bowel rest, parenteral nutrition and octreotide with variable combinations of these treatment options. 7/171 (4%) patients required operative exploration to control troublesome persistent chyle leaks. In risk factor analysis, higher tumor stage was significantly associated with the risk of chyle leak (P < 0.0001) whereas no correlation was observed with adrenal vs non-adrenal tumor location, INRG risk groups and tumor laterality. CONCLUSION Chyle leakage after surgery for neuroblastic tumors is a common morbid complication occurring in some 12% of patients. Higher INSS tumor stage portends greater risk(s). Conservative therapy strategies appear successful in the majority of cases. To avert this complication meticulous mesenteric lymphatic ligation is recommended especially for those patients with higher tumor stage(s) requiring extensive radical surgery including retroperitoneal lymph node resection. LEVEL OF EVIDENCE III. TYPE OF STUDY Systematic review.
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Affiliation(s)
- Arimatias Raitio
- University of Turku and Turku University Hospital, Paediatric Surgery, Turku, Finland.
| | - Paul D Losty
- Institute of Systems and Molecular Biology, University of Liverpool, Liverpool, UK; Department of Paediatric Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Jaleel J, Nasurudeen S, Babu AS, Gupta P, Khangembam BC, Patel C, Kumar R. Utility of 99mTc-Sulfur Colloid Lymphoscintigraphy and SPECT/CT in Chylothorax and Chylous Ascites. Nucl Med Mol Imaging 2023; 57:265-274. [PMID: 37982099 PMCID: PMC10654269 DOI: 10.1007/s13139-023-00813-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 06/21/2023] [Accepted: 06/24/2023] [Indexed: 11/21/2023] Open
Abstract
Purpose To assess the diagnostic efficacy of 99mTc-sulfur colloid lymphoscintigraphy in chylothorax and chylous ascites, and the utility of single-photon emission computed tomography-computed tomography (SPECT/CT) in localizing the sites of leaks. Methods Data from patients who underwent lymphoscintigraphy for clinical suspicion of chylothorax or chylous ascites were retrospectively analyzed. Biochemical fluid analysis was taken as the reference standard. Pleural fluid triglyceride level > 110 mg/dL (with pleural fluid/serum ratio > 1) and a cholesterol level < 200 mg/dL (with pleural fluid/serum ratio < 1) were considered confirmatory for chylothorax. Ascitic fluid triglyceride level > 200 mg/dL with a low cholesterol level (ascites fluid/serum ratio < 1) was considered confirmatory for chylous ascites. Results 26 patients (15 males, 57.7%) aged 9 months to 68 years were enrolled in the study. Based on the reference standard, 17 had chylothorax or chylous ascites (9 with surgical history). Lymphoscintigraphy was positive in 16 (with 1 false positive) and negative in 10 (with 2 false negatives). The sensitivity, specificity, negative predictive value, positive predictive value, and accuracy of lymphoscintigraphy were 88.2% (63.6-98.5%), 88.9% (51.8-99.7%), 80.0% (51.6-93.8%), 93.8% (70.1-99.0%), and 88.5% (69.9-97.6%), respectively. SPECT/CT could localize sites of leaks in 61.5% (8/13) with a localization rate of 77.8% (7/9) and 25.0% (1/4) in patients with surgical and nonsurgical causes, respectively. Conclusion 99mTc-sulfur colloid lymphoscintigraphy is a highly efficacious noninvasive modality to diagnose chylothorax or chylous ascites with a high positive predictive value. SPECT/CT could localize the sites of leaks more frequently in patients with surgical causes.
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Affiliation(s)
- Jasim Jaleel
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | | | - Anushna Sunila Babu
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Priyanka Gupta
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | | | - Chetan Patel
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Kumar
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
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Wongrukmit S, Ngamphaiboon N, Kiranantawat K, Suwanthanma W, Plumworasawat S, Boonsakan P, Pongtippan A, Phanachet P, Warodomwichit D, Shantavasinkul PC. Unusual manifestation of gastric adenocarcinoma presenting with lymphedema, chylothorax, and chylous ascites. Clin J Gastroenterol 2023; 16:822-828. [PMID: 37737943 DOI: 10.1007/s12328-023-01851-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 08/18/2023] [Indexed: 09/23/2023]
Abstract
A 62-year-old Thai man with a 2-year history of bilateral lymphedema and an unprovoked left axillary vein thrombosis presented with progressive leg, scrotal, and abdominal swelling, and shortness of breath. He denied any gastrointestinal symptoms. His lymphedema had initially been diagnosed as chronic filariasis due to positive blood tests for anti-filarial antibodies; however, treatment with anti-filarial drugs failed to improve his symptoms. Subsequently, he underwent surgical lymphaticovenular anastomosis with scrotal reduction, which proved to be of limited symptomatic relief. Later investigations revealed bilateral chylothorax and chylous ascites, with the presence of metastatic adenocarcinoma. Histopathological examination of the patient's skin and scrotum biopsy from his previous surgery revealed invasion of the lymphatics by neoplastic cells with signet ring cell formation. Gastroscopy uncovered a gastric mass, and biopsy confirmed the diagnosis of stage IV gastric adenocarcinoma with signet ring cell. He later received palliative chemotherapy. For the management of chyle leakage, he was prescribed a very low-fat diet and supplemented with parenteral nutrition. Despite treatment, he developed cutaneous metastasis and was transitioned to best supportive care. The patient passed away 14 months after diagnosis.
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Affiliation(s)
- Siree Wongrukmit
- Division of Nutrition and Biochemical Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Thung Phaya Thai, Ratchathewi, Bangkok, 10400, Thailand
| | - Nuttapong Ngamphaiboon
- Division of Medical Oncology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kidakorn Kiranantawat
- Division of Plastic and Maxillofacial Surgery, Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Weerapat Suwanthanma
- Division of General Surgery, Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sirithep Plumworasawat
- Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Paisarn Boonsakan
- Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Atcharaporn Pongtippan
- Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pariya Phanachet
- Division of Nutrition and Biochemical Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Thung Phaya Thai, Ratchathewi, Bangkok, 10400, Thailand
| | - Daruneewan Warodomwichit
- Division of Nutrition and Biochemical Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Thung Phaya Thai, Ratchathewi, Bangkok, 10400, Thailand
| | - Prapimporn Chattranukulchai Shantavasinkul
- Division of Nutrition and Biochemical Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Thung Phaya Thai, Ratchathewi, Bangkok, 10400, Thailand.
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Tri TT, Duy HP, Thuan LNA, Kiet PT, Van Khanh NH, Nhi TTY, Tran NTT, Duc NM. Gallbladder perforation following trauma in an 18-month-old child with a common bile duct cyst. Radiol Case Rep 2023; 18:4528-4532. [PMID: 37868011 PMCID: PMC10587450 DOI: 10.1016/j.radcr.2023.09.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 09/23/2023] [Accepted: 09/26/2023] [Indexed: 10/24/2023] Open
Abstract
Gallbladder rupture caused by blunt abdominal trauma is an uncommon injury, particularly in children. This condition occurs even less frequently in children with common bile duct cysts. The history is difficult to obtain, the clinical symptoms are indistinct, and their assessment is obscured by a slew of other lesions. Radiography cannot produce clear images. Thus, the diagnosis is frequently delayed and confirmed only during surgery. Case reports of gallbladder injury after abdominal trauma are relatively rare and there are only 50 case reports in literature for 100 years. Herein, we present the case of an 18-month-old girl who had a ruptured gallbladder funnel due to blunt abdominal trauma caused by domestic violence, with an early clinical presentation of septic shock and chylous effusion. The patient underwent surgery after being diagnosed with chylous ascites that had not responded to medical treatment. Based on the findings, single-stage laparoscopic surgery is confirmed to aid in the diagnosis and treatment of gallbladder injury in the presence of a common bile duct cyst.
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Affiliation(s)
- Tran Thanh Tri
- Department of General Surgery, Children's Hospital 2, Ho Chi Minh City, Vietnam
| | - Ho Phi Duy
- Department of General Surgery, Children's Hospital 2, Ho Chi Minh City, Vietnam
| | - Luu-Nguyen An Thuan
- Department of General Surgery, Children's Hospital 2, Ho Chi Minh City, Vietnam
| | - Phan Tuan Kiet
- Department of General Surgery, Children's Hospital 2, Ho Chi Minh City, Vietnam
| | | | - Truong-Thi Yen Nhi
- Department of General Surgery, Children's Hospital 2, Ho Chi Minh City, Vietnam
| | - Nguyen-Thi Tuyen Tran
- Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Nguyen Minh Duc
- Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
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Arya R, Kumar R, Kumar T, Kumar S, Anand U, Priyadarshi RN, Maji T. Prevalence and risk factors of lymphatic dysfunction in cirrhosis patients with refractory ascites: An often unconsidered mechanism. World J Hepatol 2023; 15:1140-1152. [PMID: 37970615 PMCID: PMC10642429 DOI: 10.4254/wjh.v15.i10.1140] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/14/2023] [Accepted: 10/08/2023] [Indexed: 10/24/2023] Open
Abstract
BACKGROUND The lymphatic system is crucial in maintaining the body fluid homeostasis. A dysfunctional lymphatic system may contribute to the refractoriness of ascites and edema in cirrhosis patients. Therefore, assessment of lymphatic dysfunction in cirrhosis patients with refractory ascites (RA) can be crucial as it would call for using different strategies for fluid mobilization. AIM To assessing the magnitude, spectrum, and clinical associations of lymphatic dysfunction in liver cirrhosis patients with RA. METHODS This observational study included 155 consecutive cirrhosis patients with RA. The presence of clinical signs of lymphedema, such as peau d'orange appearance and positive Stemmer sign, intestinal lymphangiectasia (IL) on duodenal biopsy seen as dilated vessels in the lamina propria with strong D2-40 immunohistochemistry, and chylous ascites were used to diagnose the overt lymphatic dysfunctions. RESULTS A total of 69 (44.5%) patients out of 155 had evidence of lymphatic dysfunction. Peripheral lymphedema, found in 52 (33.5%) patients, was the most common manifestation, followed by IL in 42 (27.0%) patients, and chylous ascites in 2 (1.9%) patients. Compared to patients without lymphedema, those with lymphedema had higher mean age, median model for end-stage liver disease scores, mean body mass index, mean ascitic fluid triglyceride levels, and proportion of patients with hypoproteinemia (serum total protein < 5 g/dL) and lymphocytopenia (< 15% of total leukocyte count). Patients with IL also had a higher prevalence of lymphocytopenia and hypoproteinemia (28.6% vs. 9.1%, P = 0.004). Seven (13%) patients with lymphedema had lower limb cellulitis compared to none in those without it. On multivariate regression analysis, factors independently associated with lymphatic dysfunction included obesity [odds ratio (OR): 4.2, 95% confidence intervals (95%CI): 1.1-15.2, P = 0.027], lymphocytopenia [OR: 6.2, 95%CI: 2.9-13.2, P < 0.001], and hypoproteinemia [OR: 3.7, 95%CI: 1.5-8.82, P = 0.003]. CONCLUSION Lymphatic dysfunction is common in cirrhosis patients with RA. Significant indicators of its presence include hypoproteinemia and lymphocytopenia, which are likely due to the loss of lymphatic fluid from the circulation. Future efforts to mobilize fluid in these patients should focus on methods to improve lymphatic drainage.
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Affiliation(s)
- Rahul Arya
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India.
| | - Tarun Kumar
- Department of Pathology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Sudhir Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Utpal Anand
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Rajeev Nayan Priyadarshi
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Tanmoy Maji
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
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Verhaeghe L, Holsbeeck AV, Bonne L, Claus E, Marrannes J, Vandenbulcke R, Jochmans I, Pirenne J, Maleux G. Therapeutic lymphangiography with ethiodized oil for the management of lymphoceles and chylous ascites. Diagn Interv Imaging 2023; 104:500-505. [PMID: 37210283 DOI: 10.1016/j.diii.2023.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/28/2023] [Accepted: 05/06/2023] [Indexed: 05/22/2023]
Abstract
PURPOSE The purpose of this study was to analyze the safety, technical success and clinical outcome of percutaneous intranodal ethiodized oil (Lipiodol®) based lymphangiography (L-LAG) for the management of refractory pelvic lymphoceles or chylous ascites using high doses of ethiodized oil. MATERIALS AND METHODS Thirty-four patients presenting with symptomatic, refractory postoperative pelvic lymphocele or chylous ascites referred for theranostic, inguinal, intranodal L-LAG treatment between May 2018 and November 2021 were retrospectively included. There were 21 men and 13 women, with a mean age of 62.7 ± 16.2 (standard deviation) years (age range: 9-86 years), who underwent a total of 49 L-LAG for the management of lymphoceles (n = 14), chylous ascites (n = 18) or a combination of lymphocele and chylous ascites (n = 2). Clinical and radiological pre-interventional, procedural and follow-up data up to January 2022 were collected from patients' electronic medical records and imaging files. RESULTS Technical success was obtained in 48 out of 49 L-LAG (98%). No complications related to L-LAG were noted. After one or more L-LAG, clinical success was obtained in 30 patients (88%) with a mean of 1.4 interventions per patient and mean intranodal injected volume of 29 mL of ethiodized oil per session. The remaining four patients (12%), with one or more failed L-LAG, underwent additional surgical intervention to definitively treat the postoperative lymphatic leakage. CONCLUSION L-LAG using high doses of ethiodized oil is a minimally invasive, safe and effective treatment of postoperative pelvic lymphocele or chylous ascites. Multiple sessions may be needed to obtain a meaningful clinical result.
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Affiliation(s)
- Laurence Verhaeghe
- Department of Radiology, General Hospital AZ Sint-Lucas/Sint-Jan, 8310 Bruges, Belgium; Department of Radiology, University Hospitals KU Leuven, 3000 Leuven, Belgium
| | - Andries Van Holsbeeck
- Department of Radiology, General Hospital AZ Sint-Lucas/Sint-Jan, 8310 Bruges, Belgium
| | - Lawrence Bonne
- Department of Radiology, University Hospitals KU Leuven, 3000 Leuven, Belgium
| | - Eveline Claus
- Department of Radiology, University Hospitals KU Leuven, 3000 Leuven, Belgium
| | - Jesse Marrannes
- Department of Radiology, General Hospital AZ Sint-Lucas/Sint-Jan, 8310 Bruges, Belgium
| | - Ruben Vandenbulcke
- Department of Radiology, General Hospital AZ Delta, 8800 Roeselare, Belgium
| | - Ina Jochmans
- Department of Abdominal Transplantation Surgery, University Hospitals KU Leuven, 3000 Leuven, Belgium
| | - Jacques Pirenne
- Department of Abdominal Transplantation Surgery, University Hospitals KU Leuven, 3000 Leuven, Belgium
| | - Geert Maleux
- Department of Radiology, University Hospitals KU Leuven, 3000 Leuven, Belgium.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Ghelfi J, Dohan A. Intranodal lymphangiography in the management of lymphoceles and chylous ascites. Diagn Interv Imaging 2023; 104:453-454. [PMID: 37349173 DOI: 10.1016/j.diii.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 06/07/2023] [Indexed: 06/24/2023]
Affiliation(s)
- Julien Ghelfi
- University of Grenoble-Alpes, 38000 Grenoble, France; Department of Radiology, Grenoble-Alpes University Hospital, 38000 Grenoble, France; Institute for Advanced Biosciences, INSERM U1209, CNRS UMR 5309, University of Grenoble-Alpes, 38000 Grenoble, France.
| | - Anthony Dohan
- Department of Radiology, Cochin Hospital, AP-HP, 74014, Paris, France; Université Paris Cité, Faculté de Médecine, 75006, Paris, France; Institut Cochin, Université de Paris, INSERM U 1016 CNRS UMR 8104, 75014 Paris, France
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Nepali A, Guragain A, Devkota K, Paudyal P, Prasad Rimal S, Kafle A, Jung Karki R, Kumari S, Shrestha R. Chylous ascites following retroperitoneal lymphadenectomy in a patient with recurrent dysgerminoma of ovary: A case report. Gynecol Oncol Rep 2023; 48:101221. [PMID: 37576351 PMCID: PMC10422095 DOI: 10.1016/j.gore.2023.101221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/26/2023] [Accepted: 06/04/2023] [Indexed: 08/15/2023] Open
Abstract
Chylous ascites is an uncommon condition of accumulation of milky fluid rich in lymph and chylomicrons in the peritoneal cavity. Post-surgical complications following dissection near the base of the mesentery, retroperitoneum, or near the cisterna chyli, malignancies (e.g., pancreatic adenocarcinomas, lymphoma, gastric carcinoma), cirrhosis, and trauma are the prime causes of chylous ascites. Here we report a rare case of chylous ascites following clearance of isolated paraaortic nodal recurrence in a 28-year-old female with dysgerminoma of ovary. The patient developed chylous ascites on the fifth day following surgery, which was confirmed by an increased drain fluid triglyceride level. She was managed conservatively with dietary modification including a high-protein and carbohydrate but low-fat-based diet mainly containing medium-chain fatty acids. Subsequently, she recovered from chylous ascites on the sixteenth day, completed second line chemotherapy, and is now doing well.
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Affiliation(s)
- Amit Nepali
- B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | | | - Karun Devkota
- Department of Radiology, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Punam Paudyal
- Department of Pathology, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Surya Prasad Rimal
- Department of Obstetrics and Gynaecology, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Awaj Kafle
- Department of Urosurgery, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Rikesh Jung Karki
- Department of Urosurgery, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Shilpi Kumari
- Department of Nutrition, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Ramesh Shrestha
- Department of Obstetrics and Gynaecology, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
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Hoa TQ, Cuong NN, My TTT, Linh LT, Hoan L, Canh PH, Tinh TQ, Chi TNK, Luu DT, Long H. Chylous ascites after donor nephrectomy: MR lymphangiography and lymphatic embolization treatment. Radiol Case Rep 2023; 18:1029-1032. [PMID: 36684632 PMCID: PMC9849999 DOI: 10.1016/j.radcr.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/02/2022] [Accepted: 12/06/2022] [Indexed: 01/07/2023] Open
Abstract
Chylous ascites results from the leakage of lipid-rich lymphatic fluid into the peritoneal cavity. Most postsurgical chylous ascites occurs following abdominal aortic surgeries. However, rarely, it is a complication after laparoscopic donor nephrectomy. Postsurgical chylous ascites are often managed with conservative treatment or surgery, but lymphatic embolization may be required. Here, we presented a 45-year-old male patient who was referred for abdominal distension for 1 week after left donor nephrectomy. The drain fluid was milky and fluid analysis revealed high concentrations of triglycerides and chylomicron, confirming diagnosis of chylous ascites. The patient was treated with conservative therapy including a low-fat diet and fluid drainage but continued to have high draining output (up to 1500-2000 mL/24 h). He underwent magnetic resonance lymphangiography and intranodal lymphangiography, revealing extravasation of contrast into the abdomen and the left renal fossa. We embolized the interstitial lymphatic of the left retroperitoneal and lymphatic vessels leak. The patient was discharged from hospital at the fifth day after intervention. In this article, we demonstrate lymphatic lesions, the safety, and success of this technique.
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Affiliation(s)
- Tran Quoc Hoa
- Urology Surgery Department, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Nguyen Ngoc Cuong
- Diagnostic Imaging and Interventional Radiology Center, Hanoi Medical University Hospital, Hanoi, Vietnam,Corresponding author.
| | - Thieu Thi Tra My
- Diagnostic Imaging and Interventional Radiology Center, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Le Tuan Linh
- Diagnostic Imaging and Interventional Radiology Center, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Le Hoan
- Respiratory Department, Hanoi Medical University, Hanoi, Vietnam
| | - Pham Hong Canh
- Diagnostic Imaging and Interventional Radiology Center, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Trieu Quoc Tinh
- Diagnostic Imaging and Interventional Radiology Center, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Tran Nguyen Khanh Chi
- Diagnostic Imaging and Interventional Radiology Center, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Doan Tien Luu
- Diagnostic Imaging and Interventional Radiology Center, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Hoang Long
- Urology Surgery Department, Hanoi Medical University Hospital, Hanoi, Vietnam
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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 J Clin Oncol 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] [What about the content of this article? (0)] [Affiliation(s)] [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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Kong PF, Xu YH, Lai ZH, Ma MZ, Duan YT, Sun B, Xu DZ. Novel management indications for conservative treatment of chylous ascites after gastric cancer surgery. World J Gastroenterol 2022; 28:6056-6067. [PMID: 36405388 PMCID: PMC9669821 DOI: 10.3748/wjg.v28.i42.6056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/15/2022] [Accepted: 10/26/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chylous ascites (CA) presents a challenge as a relatively common postoperative complication in gastric cancer (GC). Primary conservative therapy involved total parenteral nutrition, continuous low-pressure drainage, somatostatin, and a low-fat diet. Drainage tube (DT) clamping has been presented as a potential alternative conservative treatment for GC patients with CA.
AIM To propose novel conservative treatment strategies for CA following GC surgery.
METHODS The data of patients with CA after GC surgery performed at the Fudan University Shanghai Cancer Center between 2006 and 2021 were evaluated retrospectively.
RESULTS 53 patients underwent surgery for GC and exhibited postoperative CA during the study period. Postoperative hospitalization and time of DT removal showed a significant positive association (R2 = 0.979, P < 0.001). We further observed that delayed DT removal significantly extended the total and postoperative hospitalization, antibiotic usage duration, and hospitalization cost (postoperative hospitalization: 25.8 d vs 15.5 d, P < 0.001; total hospitalization: 33.2 d vs 24.7 d, P < 0.01; antibiotic usage duration: 10.8 d vs 6.2 d, P < 0.01; hospitalization cost: ¥9.2 × 104vs ¥6.5 × 104, P < 0.01). Multivariate analysis demonstrated that postoperative infection and antibiotic usage were independent factors for delayed DT removal. Furthermore, DT removal times were shorter in seven patients who underwent DT clamping (clamped DT vs normal group, 11.8 d vs 13.6 d, P = 0.047; clamped DT vs delayed group, 13.6 d vs 27.4 d, P < 0.001). In addition, our results indicated that removal of the DT may be possible after three consecutive days of drainage volumes less than 300 mL in GC patients with CA.
CONCLUSION Infection and antibiotic usage were vital independent factors that influenced delayed DT removal in patients with CA. Appropriate standards for DT removal can significantly reduce the duration of hospitalization. Furthermore, DT clamping might be a recommended option for conservative treatment of postoperative CA.
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Affiliation(s)
- Peng-Fei Kong
- Department of Gastric Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Yong-Hu Xu
- Department of Gastric Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Zhi-Hua Lai
- Department of the General Surgery, Suzhou Industrial Park Xinghai Hospital, Suzhou 215124, Jiangsu Province, China
| | - Ming-Zhe Ma
- Department of Gastric Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Yan-Tao Duan
- Department of Gastric Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Bo Sun
- Department of Gastric Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Da-Zhi Xu
- Department of Gastric Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China
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Kalchiem-Dekel O, Falcon CJ, Bestvina CM, Liu D, Kaplanis LA, Wilhelm C, Eichholz J, Harada G, Wirth LJ, Digumarthy SR, Lee RP, Kadosh D, Mendelsohn RB, Donington J, Gainor JF, Drilon A, Lin JJ. Brief Report: Chylothorax and Chylous Ascites During RET Tyrosine Kinase Inhibitor Therapy. J Thorac Oncol 2022; 17:1130-1136. [PMID: 35788405 PMCID: PMC9427698 DOI: 10.1016/j.jtho.2022.06.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/16/2022] [Accepted: 06/18/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Spontaneous chylous effusions are rare; however, they have been observed by independent investigators in patients treated with RET tyrosine kinase inhibitors (TKIs). METHODS This multicenter, retrospective study evaluated the frequency of chylous effusions in patients treated with RET TKIs. Clinicopathologic features and management of patients with chylous effusions were evaluated. RESULTS A pan-cancer cohort of 7517 patients treated with one or more multikinase inhibitor or selective RET TKI and a selective TKI cohort of 96 patients treated with selpercatinib or pralsetinib were analyzed. Chylous effusions were most common with selpercatinib (7%), followed by agerafenib (4%), cabozantinib (0.3%), and lenvatinib (0.02%); none were observed with pralsetinib. Overall, 12 patients had chylothorax, five had chylous ascites, and five had both. Time from TKI initiation to diagnosis ranged from 0.5 to 50 months. Median fluid triglyceride level was lower in chylothoraces than in chylous ascites (397 mg/dL [interquartile range: 304-4000] versus 3786 mg/dL [interquartile range: 842-6596], p = 0.035). Malignant cells were present in 13% (3 of 22) of effusions. Chyle leak was not identified by lymphangiography. After initial drainage, 76% of patients with chylothorax and 80% with chylous ascites required additional interventions. Selpercatinib dose reduction and discontinuation rates in those with chylous effusions were 47% and 0%, respectively. Median time from diagnosis to disease progression was not reached (95% confidence interval: 14.5-undefined); median time from diagnosis to TKI discontinuation was 11.4 months (95% confidence interval: 8.2-14.9). CONCLUSIONS Chylous effusions can emerge during treatment with selected RET TKIs. Recognition of this side effect is key to prevent potential misattribution of worsening effusions to progressive malignancy.
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Affiliation(s)
- Or Kalchiem-Dekel
- Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell College of Medicine, New York, New York
| | | | | | - Dazhi Liu
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Clare Wilhelm
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | - Lori J Wirth
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Subba R Digumarthy
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Robert P Lee
- Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell College of Medicine, New York, New York
| | - David Kadosh
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Robin B Mendelsohn
- Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell College of Medicine, New York, New York
| | | | - Justin F Gainor
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Alexander Drilon
- Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell College of Medicine, New York, New York
| | - Jessica J Lin
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.
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Misso K, Robert B, Magoma J, Joylene T, Msuya D. Chylous ascites and pancreatic pseudocyst on a child following blunt abdominal trauma; a case report. Int J Surg Case Rep 2022; 97:107406. [PMID: 35839653 DOI: 10.1016/j.ijscr.2022.107406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/07/2022] [Accepted: 07/08/2022] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Chylous ascites is the collection of milky-like fluid rich in triglycerides within the peritoneal cavity. It results from disruption of normal intestinal lymphatic flow. It is caused mainly by congenital anomalies, trauma, and malignancy. Chylous ascites following blunt abdominal injury is uncommon in pediatrics. Chyle duct and pancreatic injuries present a rare clinical sequela yet to be reported in the literature. Conservative management is the mainstay of treating chyle duct injuries, reserving invasive measures for unique circumstances. CASE PRESENTATION A case of an eleven-year-old female who suffered blunt thoracoabdominal trauma and sustained injuries to the chest, pancreas, and chyle duct. She had clinical signs of peritonism and decreased air entry on the right hemithorax. While she underwent abdominal exploration, the chylous ascites eventually resolved on conservative management, and the pancreatic pseudocyst was later drained percutaneously. DISCUSSION Chylous ascites and pancreatic pseudocyst is uncommon in pediatrics. While surgery is indicated in selected cases, a conservative approach is advocated in managing lymphatic leaks. Diet with low triglycerides and high protein is advocated to decrease lymph production. Treatment of pancreatic pseudocyst varies from conservative (watchful waiting) to drainage measures. CONCLUSION Although chylous ascites is not expected following trauma, has to be considered among differential free peritoneal fluid. Pancreatic injuries are common but difficult to diagnose. CT and MRCP are preferred modalities for diagnosing pancreatic injuries. While dietary modification and drainage of the chylous ascites were the mainstays in managing chyle duct injury, pancreatic pseudocyst resolved after percutaneous drainage.
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Youssef EW, Aly A, Brahmbhatt A, Moussa A, Santos E. Lymphatic Interventions in the Cancer Patient. Curr Oncol Rep 2022. [PMID: 35639331 DOI: 10.1007/s11912-022-01293-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW The incidence of lymphatic leakage (iatrogenic and non-iatrogenic) is growing in cancer population due to the increased complexity of the surgical procedures and improved overall survival in cancer patients. The purpose of this article is to review the contemporary approach in the field of percutaneous lymphatic embolization in cancer patients with lymphatic leaks. RECENT FINDINGS Since the advent of intranodal lymphangiography in 2011 alongside with the MR and CT lymphangiography, the accuracy of diagnosis of the lymphatic diseases has significantly improved significantly. These advancements have triggered a revival of minimally invasive lymphatic interventions. Lymphatic embolization is expanding from the classic indication, thoracic duct embolization, to other lymphatic disorders (chylous ascites, lymphoceles, liver lymphorrhea, protein-losing enteropathy). The growth of lymphatic research and the standardization of the lymphatic interventions require a multidisciplinary and collaborative approach between physicians and researchers.
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23
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Qin W, Diao D, Ye K, Xu X, Shu D, Zhong H, Hu Y, Yang X, Aikemu B, Zhou L, Zhang S, Xue P, Cai Z, Zheng M, Li J, Wang Q, Sun Y, Feng B. Risk factors of chylous ascites and its relationship with long-term prognosis in laparoscopic D3 lymphadenectomy for right colon cancer. Langenbecks Arch Surg 2022. [PMID: 35589848 DOI: 10.1007/s00423-022-02527-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/21/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Chylous ascites (CA) after laparoscopic D3 lymphadenectomy for right colon cancer is not rare. However, the risk factors for CA have not been fully explored. Few studies have investigated the effect of CA on long-term prognosis. METHODS The clinical data of patients with right colon cancer who underwent laparoscopic D3 lymphadenectomy in five centers from January 2013 to December 2018 were retrospectively collected. Univariate and multivariate analyses were performed to determine the clinicopathological factors associated with CA. Then, the long-term prognosis of patients with and without CA was compared by propensity score matching and Kaplan-Meier survival analysis. RESULTS The incidence of CA was 4.4% (48/1090). Pathological T stage (p = 0.025), dissection along the left side of the superior mesenteric artery (p < 0.001) and the number of retrieved lymph nodes (p < 0.001) were independent risk factors for CA. After propensity score matching, 48 patients in the CA group and 353 patients in the non-CA group were enrolled. Kaplan-Meier survival analysis indicated that CA was not associated with overall survival (p = 0.454) and disease-free survival (p = 0.163). In patients with stage III right colon cancer, there were no significant differences in overall survival (p = 0.501) and disease-free survival (p = 0.254). CONCLUSIONS Pathological T stage, number of retrieved lymph nodes, and left side dissection along the superior mesenteric artery were independent risk factors for CA after laparoscopic D3 lymphadenectomy. CA does not impair the oncological outcomes of patients.
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24
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Lu C, Wang L, Gao Q. Chylous ascites with lymphatic leakage localization: technical aspects and clinical applications. BMC Surg 2022; 22:158. [PMID: 35524233 PMCID: PMC9077892 DOI: 10.1186/s12893-022-01619-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 04/25/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Carbon nanoparticle suspension (CNS) was applied to locate the lymphatic leakage in chylous ascites (CA). However, the flow speed and distance of the CNS were particularly decreased in the following two cases (patient 5 and 6). This study aimed to investigate and improve the flow speed and distance of the CNS via a rat model. METHODS Seven patients with CA were accepted for surgery in the past two years. Clinical data were recorded. Rats were divided into two groups to confirm the hypothesis regarding whether accepting milk or orally administered food before surgery was the key factor in CA surgery with CNS. The animals were divided into 2 groups: experimental group of 5 rats receiving fat emulsion injection (2 g/kg) 30 min before the operation and control group of 5 rats receiving saline. We analyzed flow speed and distance of the CNS in two groups of rats. The hypothesis established was that CNS movements pattern differ depending on the degree of capillary lymph duct filling. Finally, the late case reconfirmed the hypothesis again. RESULTS In animal experiments, the CNS in the preoperative high-fat feeding group moved faster and over a longer distance than that in the control group (0.51 ± 0.09 cm vs. 0.19 ± 0.10 cm, respectively; p < 0.05). Based on this, the CNS was applied to the seventh patient, who had been given a diet with a slightly higher fat content 3 days before the operation, and marked improvement with a complete cure was recorded. CONCLUSIONS The capillary lymph duct was beginning to swell after dietary intake. The dilation of the lymph vessel could make it easier for the CNS to move and reach the leakage.
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Affiliation(s)
- Chaoxiang Lu
- Department of Neonatal Surgery, Xi'an Children's Hospital & The Affiliated Children Hospital of Xi'an Jiaotong University, No. 69, Xijuyuan Lane ,Lianhu District, Xi'an, Shaanxi, 710003, China
| | - Lei Wang
- Department of Neonatal Surgery, Xi'an Children's Hospital & The Affiliated Children Hospital of Xi'an Jiaotong University, No. 69, Xijuyuan Lane ,Lianhu District, Xi'an, Shaanxi, 710003, China
| | - Qi Gao
- Department of Neonatal Surgery, Xi'an Children's Hospital & The Affiliated Children Hospital of Xi'an Jiaotong University, No. 69, Xijuyuan Lane ,Lianhu District, Xi'an, Shaanxi, 710003, China.
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25
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Park J, Lee JJ, Lee JH, Shim YM. Treatment of Refractory Chylous Ascites with an Innovative Peritoneovenous Shunt: Temporary Usage of a Continuous Renal Replacement System: A Case Report. J Chest Surg 2022; 55:81-84. [PMID: 35115426 PMCID: PMC8824651 DOI: 10.5090/jcs.21.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/11/2021] [Accepted: 10/08/2021] [Indexed: 11/16/2022] Open
Abstract
Esophagectomy and esophageal reconstruction are commonly chosen as surgical options for esophageal cancer. However, prolonged untreated chyle leakage is associated with a poor prognosis. We report the case of a patient with refractory chylous ascites. To limit the ongoing fluid loss, we utilized the chylous ascites as an additional fluid source in a renal replacement therapy system. A continuous renal replacement therapy (CRRT) drainage system was modified to drain both the chylous ascites and venous blood. The ascites drainage rate was determined empirically and regulated by a dial-flow extension set. The CRRT mode was set to continuous venovenous hemodiafiltration and maintained for 7 days. After the patient was weaned from CRRT, ascites did not reaccumulate, and the patient's general condition improved dramatically. No infections related to the system occurred. This procedure temporarily alleviates symptoms and provides more time for alternative treatment strategies.
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Affiliation(s)
- Jiyoun Park
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Jun Lee
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Hee Lee
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Mog Shim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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26
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Kalia S, Narkhede A, Yadav AK, Bhalla AK, Gupta A. Retrograde transvenous selective lymphatic duct embolization in post donor nephrectomy chylous ascites. CEN Case Rep 2022; 11:1-5. [PMID: 34218419 PMCID: PMC8811106 DOI: 10.1007/s13730-021-00618-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 06/15/2021] [Indexed: 12/20/2022] Open
Abstract
Chylous ascites is a rare, potentially sinister complication in post donor nephrectomy patients which may cause significant morbidity in form of severe malnutrition and an immuno-compromised state. We present two patients with post donor nephrectomy-related chylous leaks who failed conservative treatment. In both cases, lymphangiography was done first to detect the chylous leak site in the left renal fossa, and thereafter transvenous retrograde approach via left subclavian vein with selective lymphatic duct embolization of chylous leak was done with coils and glue successfully. Chylous ascites resolved in both patients after the embolization. Hence retrograde transvenous embolization technique appears to be an effective management option for refractory chylous leaks.
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Affiliation(s)
- Shekhar Kalia
- Department of Interventional Radiology, Sir Ganga Ram Hospital, New Delhi, India
| | - Amey Narkhede
- Department of Interventional Radiology, Sir Ganga Ram Hospital, New Delhi, India
| | - Ajit Kumar Yadav
- Department of Interventional Radiology, Sir Ganga Ram Hospital, New Delhi, India.
| | | | - Arun Gupta
- Department of Interventional Radiology, Sir Ganga Ram Hospital, New Delhi, India
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27
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Bhandari G, Tiwari V, Gupta A, Bhargava V, Malik M, Gupta A, Bhalla AK, Rana DS. Chylous Ascites after Laparoscopic Donor Nephrectomy: Case Report. Indian J Nephrol 2021; 31:482-484. [PMID: 34880560 PMCID: PMC8597792 DOI: 10.4103/ijn.ijn_391_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/22/2020] [Accepted: 10/06/2020] [Indexed: 11/22/2022] Open
Abstract
Chylous ascites refers to the accumulation of chyle in the abdominal cavity. Postoperative chylous ascites is most commonly associated with abdominal aortic surgeries. However, it is a rare complication following laparoscopic nephrectomy. It causes loss of fat, protein, and antibodies causing malnutrition and immunodeficiency. Thus, it is important to treat it as early as possible. We hereby report a case of chylous ascites following laparoscopic donor nephrectomy. A 55-year-old female was admitted at our center 2 weeks after undergoing left laparoscopic donor nephrectomy with abdominal distension and constipation. USG abdomen revealed free fluid in the abdomen. Paracentesis revealed chylous ascites. The patient was started on conservative treatment, including a diet rich in proteins and low in fats; conservative treatment, however, was unsuccessful. Lymphangiography and subsequent embolization of the defect were done, and she made a full recovery.
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Affiliation(s)
- Gaurav Bhandari
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, India
| | - Vaibhav Tiwari
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, India
| | - Anurag Gupta
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, India
| | - Vinant Bhargava
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, India
| | - Manish Malik
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, India
| | - Ashwani Gupta
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, India
| | | | - D S Rana
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, India
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28
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Zheng HD, Liu YR, Chen ZZ, Sun YF, Xu CH, Xu JH. Nomogram for predicting chylous ascites after right colectomy. World J Gastrointest Surg 2021; 13:1361-1371. [PMID: 34950426 PMCID: PMC8649560 DOI: 10.4240/wjgs.v13.i11.1361] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/01/2021] [Accepted: 09/17/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Chylous ascites following right colectomy has a high incidence which is a critical challenge. At present, there are few studies on the factors affecting chylous ascites after right colectomy and especially after D3 Lymphadenectomy. A predictive model for chylous ascites has not yet been established. Therefore, we created the first nomogram to predict the incidence of chylous ascites after right hemicolectomy.
AIM To analyze the risk factors for chylous ascites after right colectomy and establish a nomogram to predict the incidence of chylous ascites.
METHODS We retrospectively collected patients who underwent right hemicolectomy between January 2012 and May 2021 and were pathologically diagnosed with cancer. Multivariate logistic regression was used to analyze the influencing factors of chylous ascites and a nomogram was established. The predictive ability was assessed by the area under the receiver operating characteristic (ROC) curve.
RESULTS Operative time, the type of operation (standard or extended), the number of lymph nodes retrieved, and somatostatin administration were considered important risk factors. Multivariate logistic regression and nomograms can be used to accurately predict whether chylous ascites occurs. The area under the ROC curve of the model is 0.770. The C-statistic of this model is 0.770 which indicates that it has a relatively moderate ability to predict the risk of chylous ascites.
CONCLUSION We found a novel set of risk factors, created a nomogram, and validated it. The nomogram had a relatively accurate forecasting ability for chylous ascites after right hemicolectomy and can be used as a reference for risk assessment of chylous ascites and whether to prevent it after surgery.
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Affiliation(s)
- Hui-Da Zheng
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou 362000, Fujian Province, China
| | - Yu-Rong Liu
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou 362000, Fujian Province, China
| | - Zhen-Ze Chen
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou 362000, Fujian Province, China
| | - Ya-Feng Sun
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou 362000, Fujian Province, China
| | - Chun-Hao Xu
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou 362000, Fujian Province, China
| | - Jian-Hua Xu
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou 362000, Fujian Province, China
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29
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Hargis PA, Henslee B, Pokala N, Bhat A. Percutaneous Lymphatic Maceration and Glue Embolization for High-output Chylous Ascites after Robot-assisted Laparoscopic Nephrectomy and Lymphadenectomy. J Clin Imaging Sci 2021; 11:56. [PMID: 34754596 PMCID: PMC8571355 DOI: 10.25259/jcis_100_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 10/14/2021] [Indexed: 11/26/2022] Open
Abstract
To propose minimally invasive percutaneous techniques in the management of high output chylous ascites, a known potential complication of retroperitoneal surgery associated with significant morbidity and mortality. Management has traditionally been based on successful treatment reported in the literature. However, refractory or high-output leaks often prove difficult to treat and there is little evidence on superior management. We report percutaneous maceration and embolization for the management of high-volume abdominal chyle leak after robot-assisted laparoscopic (RAL) radical nephrectomy and lymph node dissection for renal cell carcinoma. A 68-year-old male with incidentally found renal cell carcinoma underwent RAL radical nephrectomy with paraaortic lymph node dissection. He initially improved after surgery but developed significant abdominal pain and distension approximately 7 weeks postoperative. This proved to be chyloperitoneum. Conservative management was initiated, but after continued high-output (>1 L) fluid drainage, we pursued adjunct intervention involving Interventional Radiological percutaneous procedures. This included lymphatic maceration and glue embolization of leaking lymphatics. The patient tolerated the percutaneous procedures well with significant improvement in drain output ultimately leading to complete resolution of ascites without further complication. Similar interventions have previously been reported in the literature for cases of chylothorax with success. However, there is a lack of reports on utilizing this minimally invasive procedure for chyloperitoneum after retroperitoneal urologic surgery. We report our successful experience with percutaneous lymphatic maceration and embolization for high output chylous ascites after RAL radical nephrectomy with lymphadenectomy. We believe that early initiation utilizing these percutaneous techniques can achieve timely resolution and should be considered in the management of these patients.
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Affiliation(s)
- Paige Ashley Hargis
- School of Medicine, University of Missouri-Columbia, Columbia, Missouri, USA
| | - Brandon Henslee
- Department of Surgery, Division of Urology, University of Missouri-Columbia School of Medicine, Columbia, Missouri, USA
| | - Naveen Pokala
- Department of Surgery, Division of Urology, University of Missouri-Columbia School of Medicine, Columbia, Missouri, USA
| | - Ambarish Bhat
- Department of Radiology, Division of Interventional Radiology, University of Missouri-Columbia School of Medicine, Columbia, Missouri, USA
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30
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Lu J, Jiang Z, Wang L, Mou S, Yan H. Mycobacteria avium-related peritonitis in a patient undergoing peritoneal dialysis: case report and review of the literature. BMC Nephrol 2021; 22:345. [PMID: 34666716 PMCID: PMC8527721 DOI: 10.1186/s12882-021-02544-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mycobacteria avium (M. avium) is a species of ubiquitous slowly growing nontuberculous mycobacteria. It causes opportunistic infections. However, M. avium-related peritonitis in peritoneal dialysis (PD) patients is rare. CASE PRESENTATION A 51-year-old female end-stage kidney disease patient undergoing PD was admitted for a noninfectious complication. She presented catheter exit site drainage and slightly increased PD effluent white cell count (WCC) with polymorphonuclear predominance on admission. Exit site infection and PD-related peritonitis were diagnosed. Repeated cultures of effluent and drainage were negative. Initial empirical antibiotics and further adjustment were not rewarding. PD was terminated 2 weeks later, however, shortly the patient developed stupor, high fever, peritoneal irritation, and spontaneous chylous ascites, and showed elevated ascitic adenosine deaminase (ADA). The manifestations persisted and the patient's general condition deteriorated despite intensified antibiotic therapy. Massive parallel sequencing identified M. avium in ascites on hospital day 25, and 4-drug treatment with azithromycin, amikacin, rifampin, and ethambutol was initiated. Nevertheless, the patient died from sepsis on hospital day 30. CONCLUSIONS We report a case of PD-related M. avium peritonitis. Prolonged culture-negative peritonitis, chylous ascites, and elevated ascitic ADA may hint the possibility of mycobacterial infections. Diagnostic method allowing prompt identification of the pathogen is warranted. The prognosis can be extremely poor, and the prophylaxis and treatment should be better defined.
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Affiliation(s)
- Jifang Lu
- Department of Nephrology, Ningbo Hangzhou Bay Hospital, Ningbo, Zhejiang, China
| | - Zhou Jiang
- Department of Pathology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ling Wang
- Department of Nephrology, Ningbo Hangzhou Bay Hospital, Ningbo, Zhejiang, China.,Department of Nephrology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, No.160, Pujian Road, Pudong District, Shanghai, 200127, P.R. China
| | - Shan Mou
- Department of Nephrology, Ningbo Hangzhou Bay Hospital, Ningbo, Zhejiang, China.,Department of Nephrology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, No.160, Pujian Road, Pudong District, Shanghai, 200127, P.R. China
| | - Hao Yan
- Department of Nephrology, Ningbo Hangzhou Bay Hospital, Ningbo, Zhejiang, China. .,Department of Nephrology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, No.160, Pujian Road, Pudong District, Shanghai, 200127, P.R. China.
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31
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Lin Y, Sun Y, Lin H, Huang Y, Jiang W, Xu Z, Huang S, Ye D, Chi P. Prediction of prolonged resolution of chylous ascites after radical D3 resection for colorectal cancer: A population-based experience from a high-volume center. Eur J Surg Oncol 2021; 48:204-210. [PMID: 34462143 DOI: 10.1016/j.ejso.2021.08.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 06/18/2021] [Accepted: 08/22/2021] [Indexed: 12/24/2022] Open
Abstract
AIM This study was aimed to analyze the incidence, risk factors, and management of chylous ascites (CA) after radical D3 resection for colorectal cancer, and to construct a predicting nomogram for prolonged resolution of CA. METHOD Consecutive colorectal cancer patients who underwent radical D3 resection were included. Logistic analysis was used to identify risk factors of postoperative CA, as well as prolonged CA resolution. A predictive nomogram for prolonged resolution of CA was developed and validated internally. RESULTS Among 7167 patients included, 277 (3.8%) patients developed CA. Logistic regression analysis demonstrated that laparoscopic operation (OR 1.507; P = 0.017) and tumors fed by the superior mesenteric artery (SMA, OR 2.456; P < 0.001) were independent risk factors of postoperative CA following radical D3 surgery for colorectal cancer. Open operation (OR 0.422; P = 0.027), drainage output on the first day of treatment (OR 1.004; P = 0.016), time to oral intake (OR 1.273; P = 0.042), and time to onset (OR 1.231; P = 0.024) were independently associated with prolonged resolution of postoperative CA (≥7 days). A predictive nomogram for prolonged CA resolution was developed with a C-index of 0.725. CONCLUSION The incidence of CA after radical D3 surgery of colorectal cancer was 3.8%. Open operation, drainage output on the first day of treatment, time to oral intake, and time to onset were independently associated with prolonged resolution of postoperative CA. A nomogram may assist in tailored treatment decision-making and counseling patient with treatment strategies.
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Affiliation(s)
- Yu Lin
- Department of Colorectal Surgery, Fujian Medical University, Union Hospital, Fuzhou, Fujian, PR China
| | - Yanwu Sun
- Department of Colorectal Surgery, Fujian Medical University, Union Hospital, Fuzhou, Fujian, PR China
| | - Huiming Lin
- Department of Colorectal Surgery, Fujian Medical University, Union Hospital, Fuzhou, Fujian, PR China
| | - Ying Huang
- Department of Colorectal Surgery, Fujian Medical University, Union Hospital, Fuzhou, Fujian, PR China
| | - Weizhong Jiang
- Department of Colorectal Surgery, Fujian Medical University, Union Hospital, Fuzhou, Fujian, PR China
| | - Zongbin Xu
- Department of Colorectal Surgery, Fujian Medical University, Union Hospital, Fuzhou, Fujian, PR China
| | - Shenghui Huang
- Department of Colorectal Surgery, Fujian Medical University, Union Hospital, Fuzhou, Fujian, PR China
| | - Daoxiong Ye
- Department of Colorectal Surgery, Fujian Medical University, Union Hospital, Fuzhou, Fujian, PR China
| | - Pan Chi
- Department of Colorectal Surgery, Fujian Medical University, Union Hospital, Fuzhou, Fujian, PR China.
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32
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Vora ZA, Kandasamy D, Naranje P, Malik R. Pediatric chylous ascites treatment with combined ultrasound and fluoroscopy-guided intranodal lymphangiography. Indian J Radiol Imaging 2021; 29:226-228. [PMID: 31367098 PMCID: PMC6639871 DOI: 10.4103/ijri.ijri_424_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Chylous ascites is a form of ascites resulting from the leakage of lymph into the peritoneal cavity, which is particularly rare in children, most common etiology being an iatrogenic injury to lymphatics during surgery. Initial conservative management options include medium-chain triglycerides-based diet, somatostatin analogs, and total parenteral nutrition. If these fail, then interventions such as paracentesis with sclerotherapy, surgical ligation, or peritoneal shunts have been described. This study reports a case of a 7-year-old child with refractory chylous ascites to demonstrate a minimally invasive technique of intranodal lymphangiography with lipiodol as a viable treatment option for chylous ascites in children, particularly in cases of minor and undetectable leaks.
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Affiliation(s)
- Zainab A Vora
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | | | - Priyanka Naranje
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Rohan Malik
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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33
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Brewer CF, Al-Abed Y. Chyle leak following total colectomy for ulcerative colitis: a case report and review of the literature. Ann R Coll Surg Engl 2021; 103:e231-e233. [PMID: 34192489 DOI: 10.1308/rcsann.2020.7112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Chyle leak is a rare complication in colorectal surgery. It occurs due to disruption of the lymphatic drainage network in the abdomen or retroperitoneum. We describe the first reported case of chyle leak following total colectomy for inflammatory bowel disease. Our patient underwent total colectomy for severe ulcerative colitis not responsive to medical treatment. Four days postoperatively, a milky fluid was noted in the drainage bag. Analysis of the fluid confirmed chyle. The patient remained well and was successfully managed conservatively with a fat-free elemental diet and was discharged from hospital on day 12 postoperatively. A review of the literature suggests that conservative management with dietary modification is a common and effective management strategy; however, medical and surgical options exist for refractory cases.
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Affiliation(s)
- C F Brewer
- Broomfield University Hospital, Mid and South Essex NHS Foundation Trust, UK
| | - Y Al-Abed
- Broomfield University Hospital, Mid and South Essex NHS Foundation Trust, UK
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34
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Mitsui K, Narushima M, Ishiura R, Danno K, Sakakura Y, Banda CH. Dual imaging lymphangiography guided treatment of infantile chylothorax. J Vasc Surg Cases Innov Tech 2021; 7:492-495. [PMID: 34386679 PMCID: PMC8346552 DOI: 10.1016/j.jvscit.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/15/2021] [Indexed: 11/25/2022]
Abstract
Chylothorax is a potentially fatal postoperative complication of neck, thoracic, and abdominal surgery in children. We report the case of a 3-month-old infant who developed persistent chylothorax with respiratory insufficiency successfully managed using a microsurgical technique and intraoperative embolotherapy. This was achieved using a combination of intermittent digital X rays and live near-infrared fluorescence imaging we have termed "dual imaging lymphangiography" to guide therapy in real time. The chylothorax resolved and the patient returned to normal diet without recurrence. This microsurgical approach with dual imaging lymphangiography provides a useful tool for intraoperative visualization and treatment of complicated chylothoraces.
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Affiliation(s)
- Kohei Mitsui
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, Tsu, Japan.,Department of Plastic and Reconstructive Surgery, Aichi Medical University, Nagakute, Japan
| | - Mitsunaga Narushima
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, Tsu, Japan
| | - Ryohei Ishiura
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, Tsu, Japan
| | - Kanako Danno
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, Tsu, Japan
| | - Yosuke Sakakura
- Department of Clinical Anesthesiology, Graduate School of Medicine, Mie University, Tsu, Japan
| | - Chihena H Banda
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, Tsu, Japan
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Ushijima H, Hida JI, Haeno M, Koda M, Ueda K, Kawamura J. Successful treatment of intractable chylous ascites after laparoscopic low anterior resection using lymphangiography and embolization with lipiodol: A case report. Int J Surg Case Rep 2021; 84:106064. [PMID: 34153695 PMCID: PMC8225989 DOI: 10.1016/j.ijscr.2021.106064] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 05/22/2021] [Accepted: 06/03/2021] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE Chylous ascites (CA) is an infrequent, intractable complication that may arise after abdominal surgery. Although various attempts at treatment have been adopted, to date, none of them have been consistently effective. We describe the successful treatment of CA using lymphangiography and embolization with lipiodol. CASE PRESENTATION A 79-year-old woman underwent laparoscopic surgery for rectum cancer at another hospital. She was discharged on postoperative day (POD) 9; however, she had to be treated and hospitalized for CA three times until POD 76. She visited our hospital to undergo treatment for CA on POD 90 because the previous conservative treatment had not improved her condition. The computed tomography (CT) scans revealed ascites effusion. We performed lymphangiography and embolization with lipiodol two times. Repeated CT on POD 134 showed that the ascites had not increased. CLINICAL DISCUSSION Lymphangiography and embolization with lipiodol effectively resolved chylous leakage that occurred after abdominal surgery. Additionally, we compare the features of two groups of cases of CA: one group in which patients were treated by lymphatic intervention and the second in which patients were treated through surgical procedures. CONCLUSION We were thus able to demonstrate the clinical effectiveness of lipiodol lymphangiography in treating CA.
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Affiliation(s)
- Hokuto Ushijima
- Department of Surgery, Kindai University Faculty of Medicine, Osakasayama, Osaka 589-8511, Japan.
| | - Jin-Ichi Hida
- Department of Surgery, Kindai University Faculty of Medicine, Osakasayama, Osaka 589-8511, Japan
| | - Masahiro Haeno
- Department of Surgery, Kindai University Faculty of Medicine, Osakasayama, Osaka 589-8511, Japan
| | - Masashi Koda
- Department of Surgery, Kindai University Faculty of Medicine, Osakasayama, Osaka 589-8511, Japan
| | - Kazuki Ueda
- Department of Surgery, Kindai University Faculty of Medicine, Osakasayama, Osaka 589-8511, Japan
| | - Junichiro Kawamura
- Department of Surgery, Kindai University Faculty of Medicine, Osakasayama, Osaka 589-8511, Japan
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Amore MA, Salvia SA, Papendieck CM. Chylous cyst-venous shunt for the management of central conducting lymphatic anomaly. J Vasc Surg Cases Innov Tech 2021; 7:235-238. [PMID: 33997561 PMCID: PMC8095075 DOI: 10.1016/j.jvscit.2021.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 02/12/2021] [Indexed: 11/30/2022] Open
Abstract
We present the case of a 45-year-old man who had presented with ubiquitous chylous reflux that manifested as a bilateral inguinal chylous cutaneous fistula and a voluminous right cervical chylous cyst. He had difficulty breathing owing to compression of the airway. Anastomosis of the chylous cyst wall with the external jugular vein was performed using a valvular vein segment to prevent blood reflux. Postoperatively, anticoagulant therapy was initiated. We found this derivative surgical procedure to be an effective and minimally invasive technique for complex lymphatic anomalies.
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Affiliation(s)
- Miguel Angel Amore
- Vascular Anomalies Committee, Cardiovascular Surgery Division, Central Military Hospital, Buenos Aires, Argentina
- Angiopediatria Foundation, Buenos Aires, Argentina
- Lymphology Unit, University Hospital, Favaloro Foundation, Buenos Aires, Argentina
| | - Sofia Alexia Salvia
- Vascular Anomalies Committee, Cardiovascular Surgery Division, Central Military Hospital, Buenos Aires, Argentina
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Nguyen TK, Luong TH, Nguyen NC, Nguyen HH, Nguyen NH, Trinh HS. Successful minimal invasive treatment of chylous ascites following pancreaticoduodenectomy: A case report and review of literature. Ann Med Surg (Lond) 2021; 66:102451. [PMID: 34141422 DOI: 10.1016/j.amsu.2021.102451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 05/18/2021] [Accepted: 05/23/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction Chylous ascites is an uncommon but potentially life-threatening type of postoperative lymphatic leakage, especially following pancreaticoduodenectomy. Case presentation A 59-year-old man underwent pancreaticoduodenectomy (PD) with extended lymphadenectomy and segmental Superior Mesenteric Vein (SMV) resection for SMV-involved pancreatic ductal adenocarcinoma (PDAC). After 20th postoperative day, patient had a drain output with a milky appearance, and with a triglyceride level was 1.6 mmol/L, and the daily output volume was up to 1500 mL per day. She has been performed Conventional Lymphangiography (CLAG) to identify the broken lymphatic vessels as well as close the leakage. Following two consecutive lymphangiography, the source of chylous leakage was identified from hilar lymphatic system, and injection of Aetoxisclerol 2% into lymphatic vessels to close the leakage was performed. Partial parenteral nutrition with limited fat components or medium-chain triglyceride (MCT) was administered, and the amount of ascites decreased particularly. The drain was removed in 20th day after the second CLAG. He had no symptoms of abdominal distention after drain removal and had been discharged after 37 postoperative days (PODs). Discussion Chylous ascites is an uncommon but potentially life-threatening complication following pancreaticoduodenectomy. Portal lymphatic plexus, which was often isolated and dissected especially with extended lymphadenectomy, is potentially damaged and caused resistant chylous leakage. Newly techniques are updated and applied in diagnosis and treatment for this difficult-to-treat complication, one of them is percutaneous transhepatic Conventional Lymphangiography (CLAG). Conclusion CLAG with percutaneous transhepatic access could be effective to identify and terminate the chylous fistula from portal lymphatic plexus after pancreaticoduodenectomy. Chylous ascites is a potentially life-threatening type of lymphatic leakage, following pancreaticoduodenectomy. Portal lymphatic plexus was a potential location of lymphatic fistula due to the regularity of isolation and dissection in pancreaticoduodenectomy with extended lymphadenectomy. Conventional Lymphangiography (CLAG) is an invasion to identify the broken lymphatic vessels and close the leakage. Percutaneous transhepatic CLAG is a technique to puncture the portal lymphatic vessels, which could not be approached with other methods.
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Weniger M, D'Haese JG, Bidlingmaier E, Becker S, Ilmer M, Angele MK, Hartwig W, Werner J. Postoperative chyle leak after pancreatic surgery - Is treatment effective? J Visc Surg 2021:S1878-7886(21)00045-X. [PMID: 34023249 DOI: 10.1016/j.jviscsurg.2021.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
PURPOSE With increasing soft tissue clearance in pancreatic cancer surgery, postoperative chyle leak (CL) has become a more commonly observed complication. Recently, a new consensus definition was established by the International study group of pancreatic surgery (ISGPS). The aim of the present analysis was to evaluate risk factors and treatment options of patients with CL after pancreatic surgery. METHODS Two hundred and twenty-eight patients with serous or chylous drainage after pancreatic surgery were included in this analysis of a prospectively collected database between 01/2014 and 12/2016. Risk factors for CL and treatment options were compared. A subgroup analysis on those patients, who had drain removal despite of persistent CL with respect to the need of subsequent percutaneous drainage or reoperation within three months postoperatively, was performed. RESULTS Sixty patients with CL were identified. Of those, 41 patients were treated with medium-chain triglyceride-diet, with a median duration of therapy of 12 days. In patients with CL, the type of treatment had no effect on time to drain removal (P=0.29) and morbidity (P=0.15). Furthermore, morbidity was not increased in patients who had their drains removed despite persistent CL (P=0.84). None of the latter patients had percutaneous drainage or reoperation for CL after removal of the surgical drains. CONCLUSIONS Dietary treatment may not be very effective in treating CL. Further research is warranted to explore the effect and necessity of CL treatment.
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Athanasiadis DI, Carr RA, Painter R, Selzer D, Lee NK, Banerjee A, Stefanidis D, Choi JN. Chylous ascites in the setting of internal hernia: a reassuring sign. Surg Endosc 2021; 36:2570-2573. [PMID: 33988770 DOI: 10.1007/s00464-021-08545-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 05/04/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Chylous ascites is often reported in cases with lymphatic obstruction or after lymphatic injuries such as intraabdominal malignancies or lymphadenectomies. However, chylous ascites is also frequently encountered in operations for internal hernias. We sought to characterize the frequency and conditions when chylous ascites is encountered in general surgery patients. METHODS Data from patients who underwent operations for CPT codes related to open and laparoscopic abdominal and gastrointestinal surgery in our tertiary hospital from 2010 to 2019 were reviewed. Patients with the postoperative diagnosis of internal hernia were identified and categorized into three groups: Internal Hernia with chylous ascites, non-chylous ascites, and no ascites. Demographics, prior surgical history, CT findings, source of internal hernia, open or laparoscopic surgery, and preoperative labs were recorded and compared. RESULTS Fifty-six patients were found to have internal hernias and were included in our study. 80.3% were female and 86% had a previous Roux-en-Y gastric bypass procedure (RYGBP). Laparoscopy was the main approach for all groups. Ascites was present in 46% of the cases. Specifically, chylous ascites was observed in 27% of the total operations and was exclusively (100%) found in patients with gastric-bypass history. Furthermore, it was more commonly associated with Petersen's defect (p < 0.001), while the non-chylous fluid group was associated with herniation through the mesenteric defect (p < 0.001). CONCLUSIONS Chylous ascites is a common finding during internal hernia operations. Unlike other more morbid conditions, identification of chylous ascites during an internal hernia operation appears innocuous. However, in the context of a patient with a history of RYGBP, the presence of chylous fluid signifies the associated small bowel obstruction is likely related to an internal hernia through a patent Petersen's defect.
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Affiliation(s)
- Dimitrios I Athanasiadis
- Section of Minimally Invasive and Bariatric Surgery, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr. EH 122, Indianapolis, IN, 46202, USA
| | - Rosalie A Carr
- Section of Minimally Invasive and Bariatric Surgery, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr. EH 122, Indianapolis, IN, 46202, USA
| | - Robert Painter
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Don Selzer
- Section of Minimally Invasive and Bariatric Surgery, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr. EH 122, Indianapolis, IN, 46202, USA
| | - Nicole Kissane Lee
- Section of Minimally Invasive and Bariatric Surgery, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr. EH 122, Indianapolis, IN, 46202, USA
| | - Ambar Banerjee
- Section of Minimally Invasive and Bariatric Surgery, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr. EH 122, Indianapolis, IN, 46202, USA
| | - Dimitrios Stefanidis
- Section of Minimally Invasive and Bariatric Surgery, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr. EH 122, Indianapolis, IN, 46202, USA
| | - Jennifer N Choi
- Section of Minimally Invasive and Bariatric Surgery, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Dr. EH 122, Indianapolis, IN, 46202, USA.
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Kumar R, Anand U, Priyadarshi RN. Lymphatic dysfunction in advanced cirrhosis: Contextual perspective and clinical implications. World J Hepatol 2021; 13:300-314. [PMID: 33815674 PMCID: PMC8006079 DOI: 10.4254/wjh.v13.i3.300] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/31/2021] [Accepted: 03/10/2021] [Indexed: 02/06/2023] Open
Abstract
The lymphatic system plays a very important role in body fluid homeostasis, adaptive immunity, and the transportation of lipid and waste products. In patients with liver cirrhosis, capillary filtration markedly increases, primarily due to a rise in hydrostatic pressure, leading to enhanced production of lymph. Initially, lymphatic vasculature expansion helps to prevent fluid from accumulating by returning it back to the systemic circulation. However, the lymphatic functions become compromised with the progression of cirrhosis and, consequently, the lymphatic compensatory mechanism gets overwhelmed, contributing to the development and eventual worsening of ascites and edema. Neurohormonal changes, low-grade chronic inflammation, and compounding effects of predisposing factors such as old age, obesity, and metabolic syndrome appear to play a significant role in the lymphatic dysfunction of cirrhosis. Sustained portal hypertension can contribute to the development of intestinal lymphangiectasia, which may rupture into the intestinal lumen, resulting in the loss of protein, chylomicrons, and lymphocyte, with many clinical consequences. Rarely, due to high pressure, the rupture of the subserosal lymphatics into the abdomen results in the formation of chylous ascites. Despite being highly significant, lymphatic dysfunctions in cirrhosis have largely been ignored; its mechanistic pathogenesis and clinical implications have not been studied in depth. No recommendation exists for the diagnostic evaluation and therapeutic strategies, with respect to lymphatic dysfunction in patients with cirrhosis. This article discusses the perspectives and clinical implications, and provides insights into the management strategies for lymphatic dysfunction in patients with cirrhosis.
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Affiliation(s)
- Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Utpal Anand
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Rajeev Nayan Priyadarshi
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Patna 801507, Bihar, India
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Covello B, Miller J, Fourzali R. Splenic vein stenting for recurrent chylous ascites in sinistral portal hypertension: a case report. CVIR Endovasc 2021; 4:26. [PMID: 33656619 PMCID: PMC7930171 DOI: 10.1186/s42155-021-00213-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 02/23/2021] [Indexed: 12/23/2022] Open
Abstract
Background Sinistral portal hypertension results from obstruction or stenosis of the splenic vein and is characterized by normal portal vein pressures and liver function tests. Gastrointestinal bleeding is the most common presentation and indication for treatment. Although sinistral portal hypertension-related chylous ascites is rare, several cases have described successful treatment with portal venous, rather than splenic venous, recanalization. Splenectomy is effective in the treatment of sinistral portal hypertension-related bleeding, although recent studies have evaluated splenic vein stenting and splenic arterial embolization as minimally-invasive treatment alternatives. Splenic vein stenting may be a viable option for other presentations of sinistral portal hypertension. Case presentation A 59-year-old gentleman with a history of necrotizing gallstone pancreatitis was referred to interventional radiology for management of recurrent chylous ascites. Analysis of ascites demonstrated a triglyceride level of 1294 mg/dL. Computed tomography revealed splenic and superior mesenteric venous stricture. The patient elected to undergo minimally invasive transhepatic portal venography, which confirmed the presence of splenic vein and superior mesenteric vein stenosis. Venography of the splenic vein showed reversal of portal venous flow, multiple collaterals, and a pressure gradient of 14 mmHg. Two 10 mm × 40 mm Cordis stents were placed, which decreased the pressure gradient to 7 mmHg and resolved the portosystemic collaterals. At 6 months follow-up, the patient had no recurrent episodes of ascites. Conclusion The current case highlights the successful treatment of sinistral portal hypertension-related intractable chylous ascites treated with transhepatic splenic vein stenting. Splenic venous stent patency rates of 92.9% at 12 months have been reported. Rebleeding rates of 7.1% for splenic vein stenting, 16% for splenectomy, and 47.8% for splenic arterial embolization have been reported in the treatment of sinistral portal hypertension-related gastrointestinal bleeding. The literature regarding splenic vein stenting for sinistral portal hypertension-related ascites is less robust. Technical and clinical success in the current case suggests that splenic vein recanalization may be a safe and viable option in other sinistral portal hypertension-related symptomatology. Level of Evidence: Level 4, Case Report.
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Affiliation(s)
- Brian Covello
- Department of Radiology, Aventura Hospital & Medical Center, 20900 Biscayne Blvd, Aventura, FL, 33180, USA.
| | - Jacob Miller
- Department of Radiology, Aventura Hospital & Medical Center, 20900 Biscayne Blvd, Aventura, FL, 33180, USA
| | - Roberto Fourzali
- Department of Radiology, Aventura Hospital & Medical Center, 20900 Biscayne Blvd, Aventura, FL, 33180, USA
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Yokokawa H, Katsube T, Miyazawa M, Nishiguchi R, Asaka S, Yamaguchi K, Murayama M, Kuhara K, Usui T, Yokomizo H, Yoshimatsu K, Shimakawa T, Shiozawa S. First successful case of percutaneous transabdominal thoracic duct embolization (PTTDE) for chylous ascites resulting from laparoscopic gastric cancer surgery. Int Cancer Conf J 2021; 10:149-153. [PMID: 33782644 PMCID: PMC7947137 DOI: 10.1007/s13691-021-00468-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 01/06/2021] [Indexed: 01/21/2023] Open
Abstract
A 61-year-old woman underwent laparoscopy-assisted distal gastrectomy (LADG) with extragastric lymph node dissection (D2). Two months later, she was readmitted to hospital to be treated for chylous ascites. Oral intake was discontinued and total parenteral nutrition started, but increasing body weight and decreasing serum albumin concentration was not controllable. Percutaneous transabdominal thoracic duct embolization (PTTDE) was performed on the 8th day after the readmission. Five days after PTTDE, oral intake was resumed. Seventeen days after PTTDE, the patient was discharged without recurrence of ascites. She has remained asymptomatic. We describe here the first patient with chylous ascites two months after LADG with D2 dissection for early gastric cancer who was successfully treated by PTTDE.
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Affiliation(s)
- Hideyuki Yokokawa
- Department of Surgery, Tokyo Women’s Medical University, Medical Center East, 2-1-10 Nishiogu, Arakawa, Tokyo, 116-8567 Japan
- Department of Surgery, Saitama-ken Saiseikai Kurihashi Hospital, 714-6 Koemon, Kuki, Saitama 349-1105 Japan
| | - Takao Katsube
- Department of Surgery, Tokyo Women’s Medical University, Medical Center East, 2-1-10 Nishiogu, Arakawa, Tokyo, 116-8567 Japan
| | - Miki Miyazawa
- Department of Surgery, Tokyo Women’s Medical University, Medical Center East, 2-1-10 Nishiogu, Arakawa, Tokyo, 116-8567 Japan
| | - Ryohei Nishiguchi
- Department of Surgery, Tokyo Women’s Medical University, Medical Center East, 2-1-10 Nishiogu, Arakawa, Tokyo, 116-8567 Japan
| | - Shinichi Asaka
- Department of Surgery, Tokyo Women’s Medical University, Medical Center East, 2-1-10 Nishiogu, Arakawa, Tokyo, 116-8567 Japan
| | - Kentaro Yamaguchi
- Department of Surgery, Tokyo Women’s Medical University, Medical Center East, 2-1-10 Nishiogu, Arakawa, Tokyo, 116-8567 Japan
| | - Minoru Murayama
- Department of Surgery, Tokyo Women’s Medical University, Medical Center East, 2-1-10 Nishiogu, Arakawa, Tokyo, 116-8567 Japan
| | - Kotaro Kuhara
- Department of Surgery, Tokyo Women’s Medical University, Medical Center East, 2-1-10 Nishiogu, Arakawa, Tokyo, 116-8567 Japan
| | - Takebumi Usui
- Department of Surgery, Tokyo Women’s Medical University, Medical Center East, 2-1-10 Nishiogu, Arakawa, Tokyo, 116-8567 Japan
| | - Hajime Yokomizo
- Department of Surgery, Tokyo Women’s Medical University, Medical Center East, 2-1-10 Nishiogu, Arakawa, Tokyo, 116-8567 Japan
| | - Kazuhiko Yoshimatsu
- Department of Surgery, Tokyo Women’s Medical University, Medical Center East, 2-1-10 Nishiogu, Arakawa, Tokyo, 116-8567 Japan
- Department of Surgery, Saitama-ken Saiseikai Kurihashi Hospital, 714-6 Koemon, Kuki, Saitama 349-1105 Japan
| | - Takeshi Shimakawa
- Department of Surgery, Tokyo Women’s Medical University, Medical Center East, 2-1-10 Nishiogu, Arakawa, Tokyo, 116-8567 Japan
| | - Shunichi Shiozawa
- Department of Surgery, Tokyo Women’s Medical University, Medical Center East, 2-1-10 Nishiogu, Arakawa, Tokyo, 116-8567 Japan
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Masterson TA, Cary C, Foster RS. Lessons learned from 40 years of managing chylous ascites following RPLND. Urol Oncol 2021; 39:1-2. [PMID: 38571278 DOI: 10.1016/j.urolonc.2020.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 08/31/2020] [Accepted: 09/08/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Timothy A Masterson
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN.
| | - Clint Cary
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN
| | - Richard S Foster
- Department of Urology, Indiana University School of Medicine, Indianapolis, IN
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Hamidi Alamdari D, Amini E, Arianpoor A, Ziaeemehr A, Aliakbarian M. A Novel Approach to Recalcitrant Postoperative Chylous Ascites in Liver Re-Transplantation: A Case Report. Int J Organ Transplant Med 2021; 12:38-41. [PMID: 35509725 PMCID: PMC9013496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023] Open
Abstract
In this report we have discussed our experience with a special home-made platelet-rich plasma (PRP)-fibrin glue (FG) as a last resort for treatment of a challenging case of postoperative CA. A 25 years old, ill woman was admitted with severe ascites and hepatic encephalopathy in our center. She was a known case of autoimmune hepatitis and cirrhosis who had undergone liver transplantation 5 years ago and developed chronic rejection. During the surgery an old organized thrombosis in the portal vein was detected, accordingly an iliac vein graft was used to bypass the superior mesenteric vein. After surgery the patient developed chylous ascites. Having no other choice, based on our experience with PRP-FG in similar situations, we decided to use this method as a last resort to treat postoperative chylous ascites. It can be concluded that when conservative management is not working for the treatment of postoperative chylous ascites in intractable cases, PRP-FG can be considered as a last resort treatment. A special home-made PRP-FG was prepared for the patient and of that, 90 mL was injected to the abdominal cavity via the drainage tube followed by a 25 mL of isotonic saline solution to prevent clot formation within the tube. Few days after treatment, chylous secretion decreased and then completely ceased. It can be concluded that when conservative management is not working for the treatment of postoperative chylous ascites in intractable cases, PRP-FG can be considered as a last resort treatment.
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Affiliation(s)
- D. Hamidi Alamdari
- Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Biochemistry, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - E. Amini
- Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - A. Arianpoor
- Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - A. Ziaeemehr
- Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - M. Aliakbarian
- Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Surgery, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
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Zeng W, Hu Y, Feng J, Luo X. Chylous ascites following repair of total anomalous pulmonary venous connection coexisting with a persistent left superior vena cava in a neonate: a case report. Transl Pediatr 2021; 10:188-193. [PMID: 33633952 PMCID: PMC7882300 DOI: 10.21037/tp-20-258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Chylous ascites refers to the accumulation of lymphatic fluid in the peritoneal cavity. The causes of chylous ascites are various, and commonly include traumatic injury and obstruction, which disrupt the lymphatic system. In addition, cardiothoracic surgery may injure the thoracic duct and lead to chylothorax. However, there are very few reported cases of isolated chylous ascites developing following cardiothoracic surgery. In this paper, we report a case of postoperative chylous ascites in a full-term neonate. The infant underwent cardiothoracic surgery via thoracotomy to repair total anomalous pulmonary venous connection coexisting with a persistent left superior vena cava on day of life 17, and there was a significant increase in abdominal girth on postoperative day 12 (day of life 29). Abdominal ultrasound revealed an 8 mm thick ascites without pleural effusion. Abdominal paracentesis was performed and the milky-white peritoneal fluid was positive for Sudan III staining and the chylous test. The triglyceride concentration of the ascitic fluid was 691 mg/dL and the concentration of protein was 39.4 g/L. Additionally, the ascitic fluid also contained 6 360×106/L of white blood cells, predominantly lymphocytes. These results suggested the infant developed chylous ascites. Conservative management with fasting and medium-chain triglycerides-based formula successfully resolved the chylous ascites without reoccurrence. We present our experience of this rare condition and discuss the possible causes of chylous ascites in this case.
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Affiliation(s)
- Wen Zeng
- Department of Neonatology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yue Hu
- Surgical Intensive Care Unit, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Jun Feng
- Surgical Intensive Care Unit, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiaoli Luo
- Department of Pediatric Critical Medicine, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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Alshahrani SM, Saeed MA, Alghamdi AS, Alameri MS. Intestinal malrotation causing chylous ascites in an adolescent: a case report. Int J Surg Case Rep 2020; 77:894-8. [PMID: 33395919 DOI: 10.1016/j.ijscr.2020.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 11/30/2020] [Accepted: 12/01/2020] [Indexed: 11/21/2022] Open
Abstract
Chylous ascites due to intestinal malrotation is a rare occurrence, especially in adolescent and adult patients. Chylous ascites due to intestinal malrotation typically occurs early in life with painless distension of the abdomen. Our case is a male adolescent who presented with abdominal pain and a history of congenital hernia repair. Ladd’s procedure was successfully performed in our case with no complications.
Introduction Intestinal malrotation is a rare etiology of chylous ascites in adolescents. Chylous ascites is caused by lymphatic system disarrangement, which can result in an anomalous build-up of a lymphatic fluid rich in lipid, namely chyle in the peritoneal cavity. Presentation of case We present a case of a 16-year-old Saudi Arabian male who came to the emergency department with right upper quadrant pain associated with difficulty in passing stool for one day and a history of congenital diaphragmatic hernia (CDH) repair at the age of 4 months. Free fluid in the abdomen was noticed in the bedside ultrasound. Abdominopelvic computed tomography revealed dilated small bowel loops and a whirl sign of the mesentery, which indicated intestinal torsion. The patient was treated using Ladd’s procedure, and a large volume of chylous fluid was removed from the abdomen. Postoperatively, the abdominal drain revealed no chyle, and the patient was followed-up as an outpatient at which point, he reported no abdominal pain. Discussion Intestinal malrotation is more commonly reported in children and associated with congenital chylous ascites. Chylous ascites by itself is a rare occurrence, and very few cases attribute it to intestinal malrotation in adults. Surgical management with Ladd’s procedure is a well-documented surgery in pediatric patients, and yet it was successfully performed in our adolescent patient. Conclusion Surgical management of chylous ascites secondary to intestinal malrotation in an adolescent, which is considered novel in this age group, including peritoneal lavage of chyle, resulted in favorable outcomes.
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Fernandes V, Queirós J, Soares C. Chylous ascites: Case report of a rare presentation of blunt abdominal trauma. Int J Surg Case Rep 2020; 77:799-802. [PMID: 33395899 PMCID: PMC7724093 DOI: 10.1016/j.ijscr.2020.11.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 11/02/2022] Open
Abstract
INTRODUCTION Chylous ascites is the accumulation of a milk-like peritoneal fluid rich in triglycerides, due to the presence of intestinal lymph in the abdominal cavity. The most common causes of chylous acites in adults are abdominal malignancy and cirrhosis. Very few cases of chylous ascites associated to blunt abdominal trauma have been published in the literature. CLINICAL CASE A 27-year-old, female patient was admitted to the emergency department (ED) with abdominal pain due to a deceleration-type traffic accident. During surveillance the patient presented a progressive decrease in hemoglobin levels and an increase in free intra-abdominal fluid detected on computed tomography scan. The patient underwent an exploratory laparoscopy and a milky-looking peritoneal fluid was identified. The diagnosis of chylous ascites was confirmed by the determination of increased triglyceride levels in the peritoneal fluid. A low-fat diet, with a restriction of long-chain triglycerides, was started in the post-operative period and the patient presented a progressive decrease in abdominal drainage. The patient had a favorable clinical and analytical evolution and was discharged on the fifth post-operative day. DISCUSSION Chylous ascites is an uncommon finding in trauma. Although surgery may be indicated in selected patients, conservative treatment can be effective in most patients, with or without abdominal drainage. A high-protein and low-fat diet, with medium-chain triglycerides, is the indicated dietary regimen to decrease the amount of lymphatic fluid produced. CONCLUSION Chylous ascites, although rare in trauma patients must be considered in the diferential diagnosis of free peritoneal fluid. Conservative treatment should be considered in the majority of cases reserving invasive treatments for specific situations.
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Affiliation(s)
- Vânia Fernandes
- General Surgery Department, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal.
| | - Jacinta Queirós
- General Surgery Department, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | - Carlos Soares
- General Surgery Department, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
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Dionisio RG, Koo KS, Tang ER, Ferguson MR, Monroe EJ, Reis J, Shivaram GM, Smith CA. Combined endolymphatic and surgical treatment of a leaking central conducting lymphatic malformation in a neonate. Radiol Case Rep 2020; 16:171-174. [PMID: 33250948 PMCID: PMC7677655 DOI: 10.1016/j.radcr.2020.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/01/2020] [Accepted: 10/02/2020] [Indexed: 12/13/2022] Open
Abstract
Lymphatic malformations are congenital alterations of normal embryonic lymphatic development. We present a case of a premature 7-week-old male with a large central conducting lymphatic malformation and significant abdominal chylorrhea. He was successfully treated with combined endolymphatic and surgical approaches. To the authors’ knowledge, this is the first case to be described.
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Affiliation(s)
- Robert G Dionisio
- Department of General Surgery, University of Washington, 1959 NE Pacific St., Seattle WA 98195
| | - Kevin Sh Koo
- Department of Radiology, Section of Interventional Radiology, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle WA 98105
| | - Elizabeth Ry Tang
- Department of Radiology, Section of Interventional Radiology, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle WA 98105
| | - Mark R Ferguson
- Department of Radiology, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle WA 98105
| | - Eric J Monroe
- Department of Radiology, Section of Interventional Radiology, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle WA 98105
| | - Joseph Reis
- Department of Radiology, Section of Interventional Radiology, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle WA 98105
| | - Giridhar M Shivaram
- Department of Radiology, Section of Interventional Radiology, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle WA 98105
| | - Caitlin A Smith
- Department of Pediatric General Surgery, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle WA 98105
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Suárez-Sánchez A, Fernández-Hevia M, Díaz-Vico T, García-Munar M, García-Gutiérrez C, Fernández-Martínez D, Otero-Diez JL, García-Flórez LJ, Granero-Trancón JE. Linfografía como opción diagnóstica y terapéutica en la fuga quilosa posoperatoria de cáncer colorrectal. CIR CIR 2020; 88:43-46. [PMID: 33284282 DOI: 10.24875/ciru.20000252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
La fuga quilosa es una complicación muy poco frecuente tras la cirugía colorrectal. Se presenta el caso de un paciente de 70 años con neoplasia de recto medio intervenido de forma electiva tras un ciclo largo de neoadyuvancia mediante una resección anterior de recto por laparoscopia. El cuarto día de posoperatorio presentó un drenaje pélvico de aspecto quiloso y el día 13 se confirmó la fuga quilosa en la linfografía. Posteriormente el débito se redujo de forma rápida. La linfografía no solo es un método diagnóstico, sino que en el 35-70% de los casos puede también ser terapéutica. Chylous leakage is an extremely rare complication after colorectal surgery. We report the case of a 70 year-old male with a mid-rectal cancer who underwent a laparoscopic anterior resection of the rectum after long course neoadjuvant therapy. On postoperative day 4 the patient presented with chylous pelvic drainage, and a chylous leakage was proved by lymphography on postoperative day 13. Hereinafter, the drainage was drastically reduced. The lymphography is not only a diagnostic technique, but it can be also a therapeutic method in up to 35-70% of the cases.
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Affiliation(s)
- Aida Suárez-Sánchez
- Sección de Coloproctología, Servicio de Cirugía General, Hospital Universitario Central de Asturias, Oviedo, España
| | - María Fernández-Hevia
- Sección de Coloproctología, Servicio de Cirugía General, Hospital Universitario Central de Asturias, Oviedo, España
| | - Tamara Díaz-Vico
- Sección de Coloproctología, Servicio de Cirugía General, Hospital Universitario Central de Asturias, Oviedo, España
| | - Manuel García-Munar
- Sección de Coloproctología, Servicio de Cirugía General, Hospital Universitario Central de Asturias, Oviedo, España
| | - Carmen García-Gutiérrez
- Sección de Coloproctología, Servicio de Cirugía General, Hospital Universitario Central de Asturias, Oviedo, España
| | - Daniel Fernández-Martínez
- Sección de Coloproctología, Servicio de Cirugía General, Hospital Universitario Central de Asturias, Oviedo, España
| | - Jorge L Otero-Diez
- Sección de Coloproctología, Servicio de Cirugía General, Hospital Universitario Central de Asturias, Oviedo, España
| | - Luis J García-Flórez
- Sección de Coloproctología, Servicio de Cirugía General, Hospital Universitario Central de Asturias, Oviedo, España
| | - José E Granero-Trancón
- Sección de Coloproctología, Servicio de Cirugía General, Hospital Universitario Central de Asturias, Oviedo, España
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Kwon LM, Hur S, Jeong CW, Jae HJ, Chung JW. Glue Embolization of Lymphopseudoaneurysm for Chylous Ascites after Retroperitoneal Surgery. Korean J Radiol 2020; 22:376-383. [PMID: 32901460 PMCID: PMC7909856 DOI: 10.3348/kjr.2020.0056] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 04/25/2020] [Accepted: 05/26/2020] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To assess the safety and efficacy of lymphopseudoaneurysm (LPA) glue (n-butyl cyanoacrylate [NBCA]) embolization in the management of chylous ascites after retroperitoneal surgery. MATERIALS AND METHODS A retrospective analysis from January 2014 to October 2018 was performed in six patients (4 females and 2 males; mean age, 45.3 ± 14.2 years; range, 26-61 years) who underwent LPA embolization for chylous ascites developing after retroperitoneal surgery involving the perirenal space (four donor nephrectomies, one partial nephrectomy, and one retroperitoneal lymphadenectomy). After placing a percutaneous drainage catheter into the LPA or adjacent lymphocele, embolization was performed by filling the LPA itself with a mixture of glue and Lipiodol (Guerbet). RESULTS Daily drainage from percutaneously placed drains exceeded 300 mL/day despite medical and surgical treatment (volume: mean, 1173 ± 1098 mL; range, 305-2800 mL). Intranodal lymphangiography was performed in four of the six patients and revealed leakage in 2 patients. Percutaneous embolization of the LPA was successful in all patients using an NBCA and Lipiodol mixture in a ratio of 1:1-1:2 (volume: mean, 4.3 ± 1.1 mL; range, 3-6 mL). Chylous ascites was resolved and the drainage catheter was removed in all patients within 4 days after the procedure (mean, 2.0 ± 1.8 days; range, 0-4 days). No procedure-related complications or recurrence of chylous ascites occurred during a mean follow-up period of 37.3 months (range, 21.1-48.4 months). CONCLUSION Glue embolization of LPA has the potential to be a feasible and effective treatment method for the management of chylous ascites after retroperitoneal surgery.
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Affiliation(s)
- Lyo Min Kwon
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Saebeom Hur
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.
| | - Chang Wook Jeong
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea
| | - Hwan Jun Jae
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Jin Wook Chung
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
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