Combined occurrence of chyloperitoneum and chylothorax after surgery and chemotherapy for Wilms' tumor

Surgical outcomes according to the type of monopolar electrocautery device used in laparoscopic surgery for right colon cancer: a comparison of endo-hook versus endo-shears

BACKGROUND

Although monopolar electrocautery is preferred by many laparoscopic surgeons and is more cost-effective than bipolar or ultrasonic scissors, few studies have compared these outcomes between different monopolar electrocautery devices used in laparoscopic surgery. Therefore, this study compared the surgical outcomes between monopolar endo-hook versus endo-shears during laparoscopic right hemicolectomy for right colon cancer.

METHODS

Using a prospective database of patients treated at our institute, we analyzed the surgical outcomes of 358 consecutive patients with right colon cancer who underwent curative laparoscopic surgery with a monopolar endo-hook (n = 164) or endo-shears (n = 194) between March 2009 and March 2017.

RESULTS

There were no differences in age, sex, body mass index, American Society of Anesthesiologists' grade, previous operative history, or clinical stage between the endo-hook and endo-shears groups. The estimated blood loss was similar between the endo-hook and endo-shears groups (90.9 ± 60.3 vs. 92.0 ± 89.3 mL; P = 0.893). The number of harvested lymph nodes was greater in the endo-hook group (53.5 ± 20.3 vs. 48.1 ± 18.5; P = 0.008). Hospital stay was shorter in the endo-hook group (6.8 ± 2.2 vs. 7.8 ± 4.8 days; P = 0.013). Although chylous ascites was more frequent in the endo-hook group (21.3% vs. 7.7%, P < 0.001), the postoperative morbidity rate was lower in this group (9.8% vs. 18.0%; P = 0.025). All instances of chylous ascites healed spontaneously without intervention.

CONCLUSIONS

This study showed that the use of a monopolar endo-hook during laparoscopic right hemicolectomy might permit more meticulous lymph-node dissection and reduce morbidity compared with the use of monopolar endo-shears. Therefore, we suggest that the outcomes of laparoscopic surgery might be associated with the type of electrocautery device used.

Late-onset chylothorax during chemotherapy after lobectomy for lung cancer: A case report and review of the literature

RATIONALE

Chylothorax is usually diagnosed within a few days after lobectomy. Late-onset chylothorax following trauma or thoracic surgery is rare but potentially lethal, lacking reliable preventive methods.

PATIENT CONCERNS

A 54-year-old male patient complained of dyspnea during adjuvant chemotherapy on the 35th postoperative day after right middle lobectomy and systemic lymph node dissection (SLND) for lung cancer. His computed tomography indicated massive pleural effusion filling in the right chest cavity.

DIAGNOSES

The patient was primarily diagnosed as late-onset chylothorax, without definite evidence to exclude spontaneous chylous leakage.

INTERVENTIONS

Uniportal video-assisted thoracoscopic thoracic duct ligation (TDL) was performed for him, as conservative treatment using octreotide with fat-free diet turned out to be ineffective.

OUTCOMES

His pleural effusion was gradually diminished after reoperation, and the patient was discharged 9 days after TDL.

LESSONS

Postoperative late-onset or spontaneous chylothorax should be kept in mind after pulmonary resection and SLND, and the exclusion of chylous leakage could be considered as a precondition of chest tube removal.

A Large Pleural Effusion following Abdominal Aortic Surgery

Chylous ascites and coexistent chylothorax is a rare but important complication following retroperitoneal abdominal surgery. We report a 70-year-old male who developed gradual abdominal distension, chest tightness, and dyspnea five months after having an uncomplicated aortobifemoral bypass performed. Physical examination was consistent with a large right sided effusion and ascites which were confirmed by computed tomography. Thoracentesis yielded an opaque milky fluid with analysis consistent with a chylothorax with a paracentesis revealing fluid that was similar in both appearance and biochemistry. The patient failed initial conservative management so a chest tube was placed followed by chemical pleurodesis. We review the literature of the pathophysiology and treatment approach to such a pleural effusion.

Chylothorax in infants and children

Chylothorax, the accumulation of chyle in the pleural space, is a relatively rare cause of pleural effusion in children. It can cause significant respiratory morbidity, as well as lead to malnutrition and immunodeficiency. Thus, a chylothorax requires timely diagnosis and treatment. This review will first discuss the anatomy and physiology of the lymphatic system and discuss various causes that can lead to development of a chylothorax in infants and children. Then, methods of diagnosis and treatment will be reviewed. Finally, complications of chylothorax will be reviewed.

Chylous ascites after nephrectomy without lymphadenectomy for malignant rhabdoid tumor of the kidney: A rare occurrence and literature review

Chylous ascites (CA) is an extremely rare complication of abdominal surgery in children. This report describes a 4-month-old girl with malignant rhabdoid tumor of the kidney (MRTK), who developed CA after left nephrectomy without lymphadenectomy, and who was successfully treated conservatively with enteral therapy. The literature on CA after nephrectomy without lymphadenectomy for MRTK is reviewed herein, and the clinical problems of postoperative CA are discussed.

Incidence and management of chyle leaks following pancreatic resection: a high volume single-center institutional experience

BACKGROUND

No data on incidence, management, or natural history of chyle leaks following pancreatic resection have been published. We sought to identify possible risk factors associated with chyle leaks following pancreatic resection, as well as determine the natural history of this rare complication.

METHODS

Between 1993 and 2008, 3,532 patients underwent pancreatic resection at a single institution. Data on demographics, operative details, primary tumor status, and chyle leak were collected. To identify risk factors associated with chyle leak, a matched 3:1 paired analysis was performed.

RESULTS

Of 3,532 patients undergoing pancreatic resection, 47 (1.3%) developed a chyle leak (n = 34, contained chyle leak versus n = 13, diffuse chylous ascites). Chyle leak was identified at median 5 days following surgery. Median drain triglyceride levels were 592 ng/dl. After matching on tumor size, disease etiology, and resection type, the number of lymph nodes harvested and history of concomitant vascular resection predicted higher risk of chyle leak (both P < 0.05). Total parenteral nutrition (TPN) was required in more patients with chylous ascites (92.3%) than those with chyle leaks (44.1%) (P = 0.003). The median time to resolution was shorter for contained chyle leaks (13 days) versus chylous ascites (36 days) (P < 0.001). Patients with chylous ascites tended to have shorter overall survival (3-year, 18.8%) versus patients with no chyle leak (3-year, 46.9%) (P = 0.12). In contrast, patients with a contained chyle leak had a similar survival as patients with no chyle leak (3-year, 53.4% versus 46.9%, respectively) (P = 0.32).

CONCLUSION

Chyle leak was a rare (1.3%) complication following pancreatic resection that was associated with number of lymph nodes harvested and concomitant vascular resection. In general, chyle leaks were successfully managed with TPN with no adverse impact on outcome. Patients with chylous ascites, however, had a more protracted clinical course and tended to have a worse long-term survival.

Successful treatment for intractable chylous ascites in a child using a peritoneovenous shunt

Intractable post-operative chylous ascites had been managed successfully using a peritoneovenous shunt (PVshunt). A 4-year-old girl with neuroblastoma originated from the right adrenal gland was admitted to our hospital. Following the preoperative chemotherapy, tumor resection, and lymph node dissection of the abdominal paraaortic region were carried out. Post-operative radiation therapy 9.6 gray to the tumor bed and to the paraaortic region and a high dose chemotherapy supported by auto bone marrow transplantation were completed. Three months later some enlarged lymph nodes along the duodeno-hepatic ligament were detected and these had gradually increased in size. Lymph node dissection along the hepatic artery and the abdominal aorta was carried out. Pathological examination of the specimen showed reactive lymph node swelling. Chylous ascites developed several days after surgery. Despite the medium-chain triglycerides meal or total parental nutrition, the ascites persisted for more than 80 days. Multiple paracenteses were mandatory. A PV shunt was implanted and the ascites was resolved by the fourth post-operative day. Thirty months later, the vascular end tube of the shunt was ligated. As ascites had not accumulated for 2 weeks, the PV shunt was removed. The patient has been doing well without recurrence of ascites or neuroblastoma for 12 years. As PV shunts were mostly used for long lasting disease, it has not been referred as to how to know when the shunt should be removed. If the shunt is inserted for transient management of ascites, less invasive methods of investigation to know when to remove the shunt need to be developed.

Chylous Ascites Following Surgical Treatment for Wilms Tumor

PURPOSE

Postoperative chylous ascites is a rare complication of retroperitoneal surgery that has considerable morbidity. We review the pathogenesis and management of chylous ascites following surgical treatment of Wilms tumor.

MATERIALS AND METHODS

We identified 9 children with chylous ascites after surgical treatment of Wilms tumor. Of these cases 3 were treated at a single institution during the last 20 years and 6 were identified during retrospective chart reviews of patients enrolled in National Wilms Tumor Studies 3 and 4 to identify surgical complications. Chylous ascites presented as increased abdominal girth and poor feeding. Paracentesis or laparotomy was diagnostic.

RESULTS

Patient age at presentation with Wilms tumor ranged from 6 to 95 months (median 15). Left nephrectomy was performed in 5 cases, right nephrectomy in 3, and left nephrectomy and partial right nephrectomy in 1 with bilateral disease. Lymphadenectomy including the hilar and periaortic lymph nodes was performed in 5 patients, 4 of whom also underwent some form of suprahilar lymph node dissection. Three patients underwent lymph node sampling of the hilar, periaortic and some suprahilar lymph nodes. All children received adjuvant chemotherapy and 4 were treated with adjuvant irradiation to the surgical bed before the diagnosis of chylous ascites. The interval between surgery and diagnosis of ascites ranged from 12 to 49 days (median 21). Of the patients 7 were successfully treated with conservative measures, total parenteral nutrition and/or a diet containing primarily medium chain triglycerides, and 2 required invasive procedures, including exploratory laparotomy and ligation of disrupted lymphatic vessels or placement of a peritoneovenous shunt.

CONCLUSIONS

Extensive lymph node dissection, particularly above the level of the renal hilum, appears to be associated with the development of postoperative chylous ascites. The National Wilms Tumor Study guidelines do not require formal lymph node dissection for staging and only lymph node sampling is recommended. Elimination of formal lymphadenectomy along with meticulous ligation of lymphatics should decrease the incidence of this complication. Fortunately, conservative treatment with total parenteral nutrition and/or medium chain triglycerides will remedy the problem in the majority of children.

[Reoperation for refractory postoperative chylous ascites: value of peritoneovenous shunt combined with closure of lympho-peritoneal fistula]

Postoperative chylous ascites is a rare but serious complication resulting in denutrition, lymphopenia and infection. The first-intent treatment is usually conservative. We report a case of chylous ascites after retroperitoneal lymphadenectomy for testicular cancer, persisting despite conservative treatment then successfully treated by lymphostasis combined with peritoneovenous shunt. In case of high-output postoperative chylous ascites in low-risk patients with presumed localization of fistula, reoperation is indicated for lymphostasis. We advise to associate a peritoneovenous shunt in case of incomplete closure of the lymphoperitoneal fistula to avoid the morbidity of prolonged ascites.

The diagnosis and management of postoperative chylous ascites

PURPOSE

Postoperative chylous ascites is a rare complication of retroperitoneal and mediastinal surgery that represents a difficult management problem due to the serious mechanical, nutritional and immunological consequences of the constant loss of protein and lymphocytes. We reviewed the topic of postoperative chylous ascites with special emphasis on the relevant diagnostic and imaging modalities. We propose a novel management algorithm.

MATERIALS AND METHODS

We performed a MEDLINE search of the literature on chylous ascites using chyloperitoneum as the subject heading and chylous ascites as an additional key word. The search yielded 651 articles. We focused on 102 series, collective reviews and mainly case reports related to the issue of postoperative chylous ascites.

RESULTS

We propose a novel algorithm based on a step-up approach aimed at promoting decreased lymph production and flow as well as maintaining nutritional balance. The management algorithm integrates repeat palliative paracentesis, dietary measures, total parenteral nutrition therapy, peritoneovenous shunting and surgical closure of the lymphoperitoneal fistula. Due to the remarkable effectiveness of somatostatin therapy for the closure of lymphatic fistula somatostatin therapy should be attempted with or without total parenteral nutrition early in the course of treatment of chylous ascites before any invasive steps are taken.

CONCLUSIONS

Various management modalities may be used successfully to treat chylous ascites. Therefore, treatment should be individualized and adjusted to the severity of lymphatic leakage and its consequences. The outcome mostly depends on the underlying pathological condition. Thus, in the absence of malignant or congenital underlying pathology the prognosis in cases of postoperative chylous ascites is good with the majority responding to conservative measures.

Chylous ascites after oncological abdominal surgery: incidence and treatment

AIMS

Chylous ascites can be a problem after oncological abdominal surgery. The aim of this study was to report the incidence and the management of the problem.

METHODS

A retrospective study over a 2-year period of all oncological patients undergoing abdominal surgical procedures was carried out. Patients with resections in the upper abdomen and retroperitoneum were studied in more detail.

RESULTS

Twelve (7.4%) of 163 patients with complex surgical procedures developed a chyloperitoneum. Chylous ascites stopped in time with conservative management in nine patients. Three patients had a peritoneovenous shunt inserted with success. No relaparotomies to ligate leaking intestinal lymph vessels were necessary.

Postoperative chylous ascites

The case of an infant, aged 2 months and 23 days, with chylous ascites after nephrectomy is reported. Nephrectomy was performed because of a large hydronephrosis. Chylous ascites was treated with medium-chain triglycerides, diet and cholestyramine. After 3 days the volume of the abdomen was reduced and on day 8 chylous ascites was not visible clinically or ultrasonographically.

Alteration of Wilms' tumor staging by cytologic detection of malignant cells in chylous ascites

Accurate staging as per National Wilms' Tumor Study (NWTS) criteria is essential for therapy of Wilms' tumor. We report a unique case of a 9-mo-old white male in whom the diagnosis based upon clinical, radiological, surgical, and initial histopathologic findings was Stage I Wilms' tumor without regard to a positive cytologic examination of a small amount (5 ml) of chylous ascitic fluid obtained intraoperatively. This problem was clarified later at the NWTS panel review when the deeper recuts of a renal hilar lymph node revealed a single cluster of Wilms' tumor cells in capsular sinus, resulting in upstaging of tumor to Stage III. The significance of these findings in relation to staging will be discussed.

Aggressive inflammatory pseudotumor of the abdomen 9 years after therapy for Wilms tumor. A complication, coincidence, or association?

BACKGROUND

Inflammatory pseudotumor (IPT) is a benign lesion that occurs in various organs and tissues. It is usually sharply demarcated from the surrounding tissue and surgery is considered to be the best treatment.

METHODS

This article discusses a 15-year-old boy with an aggressive IPT of the abdomen occurring 9 years after therapy for Wilms tumor.

RESULTS

IPT widely involved the esophagus, stomach, and liver, producing severe dysphagia. Histologically, it showed classic features of IPT and, also, areas of metaplastic bone, a new feature recently described in the same lesion of the kidney. It mimicked malignant tumor clinically and led to extensive surgery, but early follow-up has shown no recurrence.

CONCLUSION

Although many complications of surgery and chemotherapy are well known, the authors believe that it is unlikely to be the cause of IPT in the case presented. Therefore, the possibility of coincidence or association of Wilms tumor and IPT remains open.