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Sarangi SS, Bhirud DP, Sandhu AS, Aggarwal A, Singh M, Navriya SC, Choudhary GR. Post-operative chyle leak following nephrectomy: Inference from tertiary care center and review of literature. Urologia 2024; 91:33-41. [PMID: 37650375 DOI: 10.1177/03915603231193189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
OBJECTIVES Lymphatic channels (LC) are not as prominent as blood vessels, so they tend to get damaged during surgical procedures. It can present with chyle leak in the postoperative period. We aimed to study the occurrence of chyle leak in patients undergoing nephrectomy and its management. METHODS During the period of January 2021 and January 2023, 158 adult patients underwent nephrectomy for various reasons like non-functioning kidney, donor nephrectomy, and malignancy. We retrospectively analyzed data of patients who had chyle leak after nephrectomies. RESULTS Eight patients out of the 158 patients (5.06%) undergoing nephrectomy developed chyle leak. One out of these eight patients underwent nephrectomy by open approach while seven underwent laparoscopic approach. All eight patients who had chyle leak undergone left sided nephrectomy. Six patients of chyle leak could be managed with dietary modification while two patients needed octreotide therapy for treatment. Higher Body Mass Index (BMI; p-value = 0.012), left sides nephrectomy (p-value = 0.013), h/o pyelonephritis (p-value = 0.005) were associated with higher incidence of chyle leak on univariate analysis. While on multivariate analysis no factor was found to be independently associated with chyle leak. Hospital stay was significantly prolonged in patients with chyle leak (p-value = 0.007). CONCLUSION Chyle leak is not a very rare complication after nephrectomy. Patients with higher BMI, who undergo left sided nephrectomies and patients who had history of pyelonephritis or infectious complications had higher incidence of chyle leak. Most cases can be managed with conservative management (CM). Chyle leak is associated with a prolonged hospital stay.
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Affiliation(s)
- Shakti Swarup Sarangi
- Department of Urology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Deepak Prakash Bhirud
- Department of Urology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Arjun Singh Sandhu
- Department of Urology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Amit Aggarwal
- Department of Urology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Mahendra Singh
- Department of Urology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Shiv Charan Navriya
- Department of Urology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Gautam Ram Choudhary
- Department of Urology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Ebada HE, Montasser MF, Abdelghaffar MF, Bahaa MM, Elbaset HSA, Sakr MA, Dabbous HM, Montasser IF, Hassan MS, Aboelmaaty ME, Elmeteini MS. Ascites post-living donor liver transplantation: Risk factors and outcome. JOURNAL OF LIVER TRANSPLANTATION 2022. [DOI: 10.1016/j.liver.2022.100112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Risk factors of chylous ascites and its relationship with long-term prognosis in laparoscopic D3 lymphadenectomy for right colon cancer. Langenbecks Arch Surg 2022; 407:2453-2462. [PMID: 35589848 DOI: 10.1007/s00423-022-02527-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [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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Sun Y, Deng Y, Lin Y, Lin H, Huang Y, Jiang W, Chi P. Chylous ascites after complete mesocolic excision for right-sided colon cancer with D3 lymphadenectomy: A retrospective cohort-study. Colorectal Dis 2022; 24:461-469. [PMID: 34878703 DOI: 10.1111/codi.16017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 11/03/2021] [Accepted: 12/01/2021] [Indexed: 02/08/2023]
Abstract
AIM This retrospective study was designed to evaluate risk factors of the occurrence and severity of chylous ascites after complete mesocolic excision (CME) and D3 lymphadenectomy in patients with right-sided colon cancer. METHODS Consecutive patients receiving CME and D3 lymphadenectomy for right-sided colon cancer were included. Risk factors of the occurrence and severity of chylous ascites by using logistic analysis were assessed. A nomogram predicting chylous ascites was constructed. RESULTS Among 661 patients included in the study, postoperative chylous ascites occurred in 48 (7.3%) patients. Logistic regression analysis demonstrated that prognostic nutritional index (PNI ≤ 47, OR = 2.172, p = 0.016), laparoscopic surgery (OR = 2.798, p = 0.034), operating time (>225 min, OR = 2.645, p = 0.002), and apical lymph node (APN) metastasis (OR = 3.698, p = 0.034) were correlated with the occurrence of postoperative chylous ascites. A nomogram predicting postoperative chylous ascites was constructed (C-index 0.701). 31.2% (15/48) of patients with chylous ascites were resolved in more than 7 days. The number of retrieved lymph nodes (OR = 1.074, 95% CI: 1.002-1.152, p = 0.044) and PNI ≤ 47 (OR = 7.890, 95% CI: 1.224-50.869, p = 0.030) were independently predictive of prolonged chylous ascites resolution (≥7 days). CONCLUSIONS In our series, 7.3% of patients developed chylous ascites after right hemicolectomy with CME and D3 lymphadenectomy. Laparoscopic surgery, PNI, operation time, and APN metastasis were independently predictive of postoperative chylous ascites. Lower PNI and more retrieved lymph nodes were correlated with prolonged resolution of chylous ascites.
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Affiliation(s)
- Yanwu Sun
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Yu Deng
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Yu Lin
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Huiming Lin
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Ying Huang
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Weizhong Jiang
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Pan Chi
- Department of Colorectal Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
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Du M, Wang L, Zhao L, Huang W, Fang X, Xia X. Independent Risk Factors of Postoperative Lymphatic Leakage in Patients with Gynecological Malignant Tumor: A Single-Center Retrospective Study. Med Sci Monit 2021; 27:e932678. [PMID: 34226438 PMCID: PMC8272396 DOI: 10.12659/msm.932678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background We aimed this investigation to screen and analyze the risk factors of postoperative lymphatic leakage of gynecological malignant tumors that contribute to the treatment of the diseases. Material/Methods According to the occurrence of lymphatic leakage after an operation, 655 patients with pelvic lymph node and/or abdominal para-aortic lymph node dissection for gynecological malignant tumor were retrospectively analyzed and divided into a case group and a control group. Univariate and multivariate logistic regression analysis were used to screen the effective independent risk factors and establish a clinical prediction model. The differentiation and calibration of the clinical prediction model were evaluated, and we performed internal and external validation of the model with 207 cases. Results The surgeons, the number of removed lymph nodes, the field and range of lymph nodes to be removed, the method of drainage, and postoperative infection are the independent risk factors of lymphatic leakage after lymph node dissection for gynecological malignant tumors. The area under the ROC curve of the clinical prediction model was 0.839 (P<0.001), the calibration Hosmer-Lemeshow test shows χ2=4.381, P=0.821. Through 10-fold cross-validation, the average correct rate of the prediction model was 0.899, the area under the ROC curve of the external verification group was 0.741, and the calibration Hosmer-Lemeshow test showed χ2=12.728, P=0.122. Conclusions The new logistic prediction model showed a good degree of differentiation and calibration in both the modeling and verification groups, and it can be used for early warning of the occurrence of lymphatic leakage after lymph node dissection.
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Affiliation(s)
- Min Du
- Department of Obstetrics and Gynecology, Second Xiangya Hospital, Central South University, Changsha, Hunan, China (mainland).,Department of Obstetrics and Gynecology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
| | - Lei Wang
- The NHC Key Laboratory of Carcinogenesis and The Key Laboratory of Carcinogenesis and Cancer Invasion of the Chinese Ministry of Education, Cancer Research Institute, School of Basic Medical Science, Central South University, Changsha, Hunan, China (mainland)
| | - Liyun Zhao
- Department of Obstetrics and Gynecology, Second Xiangya Hospital, Central South University, Changsha, Hunan, China (mainland)
| | - Wei Huang
- Research Center of Carcinogenesis and Targeted Therapy, Xiangya Hospital, Central South University, Changsha, Hunan, China (mainland).,The Higher Educational Key Laboratory for Cancer Proteomics and Translational Medicine of Hunan Province, Xiangya Hospital, Central South University, Changsha, Hunan, China (mainland)
| | - Xiaoling Fang
- Department of Obstetrics and Gynecology, Second Xiangya Hospital, Central South University, Changsha, Hunan, China (mainland)
| | - Xiaomeng Xia
- Department of Obstetrics and Gynecology, Second Xiangya Hospital, Central South University, Changsha, Hunan, China (mainland)
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Takata K, Nakazawa T, Miyagi M, Saito W, Imura T, Shirasawa E, Kuroda A, Kawakubo A, Mimura Y, Yokozeki Y, Takaso M, Inoue G. Chylous retroperitoneum following 720 degree anteroposterior-combined corrective surgery for adult spinal deformity with split vertebral fracture subluxation: a case report. Spine Deform 2021; 9:1183-1189. [PMID: 33651339 DOI: 10.1007/s43390-021-00309-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 02/08/2021] [Indexed: 11/30/2022]
Abstract
STUDY DESIGN Clinical case report. PURPOSE To report the rare case with post-operative chylous retroperitoneum after corrective surgery for adult spinal deformity. METHODS We present a case of a 73-year-old woman with Parkinson's disease. She sustained a severe split fracture subluxation of the L3 vertebra with AO Spine Thoracolumbar classification type CN2M2, resulting in severe kyphoscoliosis in global alignment. She underwent a two-stage 720-degree anteroposterior-combined corrective surgery with anterior vertebral column resection of L3 and posterior fusion from T4 to the pelvis. On post-operative day 1, milky fluid in the drainage tube was noted, which was diagnosed as post-operative chylous retroperitoneum. RESULTS Oral intake was discontinued immediately and peripheral parenteral nutrition was started. A low-fat, high-protein diet was started on post-operative day 4, and drainage was removed on day 6. A low-fat diet was continued until 3 months post-operatively, with dietary counselling by a nutritionist. The chylous retroperitoneum resolved without recurrence at the final follow-up evaluation at 3 years. CONCLUSION Surgeons should recognize this rare complication, which might be induced by direct damage to the lymphatic flow during an operative maneuver anterior to the lumbar vertebral body and indirect damage due to shearing force during correction of a subluxated vertebra, especially in cases with a severe deformity.
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Affiliation(s)
- Ken Takata
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitazato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Toshiyuki Nakazawa
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitazato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Masayuki Miyagi
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitazato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Wataru Saito
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitazato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Takayuki Imura
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitazato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Eiki Shirasawa
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitazato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Akiyoshi Kuroda
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitazato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Ayumu Kawakubo
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitazato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Yusuke Mimura
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitazato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Yuji Yokozeki
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitazato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Masashi Takaso
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitazato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Gen Inoue
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1, Kitazato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan.
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7
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CAMPISI C, WITTE M, CAMPISI CS, MOLINARI L, FULCHERI E, VILLA G, SUKKAR SG, DE CARO G, ROSSI U, PETROCELLI F, TACCHELLA M, MARENCO R, RISSO R, DEMORO A, CAMPISI CC. Matching primary with secondary lymphedemas across lymphatic surgery in Genoa (Italy) from 1973 until time of COVID-19. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2021. [DOI: 10.23736/s1824-4777.21.01495-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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8
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Nawabi A, Kahle AC, Baral P, King CD, Nawabi P. Lymphangiography with lipiodol as a diagnostic and therapeutic approach for Chyle Leak ascites following Simultaneous Pancreas-Kidney Transplant. J Surg Case Rep 2021; 2021:rjab029. [PMID: 33747430 PMCID: PMC7955963 DOI: 10.1093/jscr/rjab029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 01/19/2021] [Indexed: 11/21/2022] Open
Abstract
Chylous ascites (CA) is the leakage of triglyceride-rich fluid into the peritoneal cavity. This most commonly occurs due to trauma of the lymphatic system. Recently, lymphangiography with lipiodol have been used with promising results in managing refractory postoperative CA. We present the case of a 35-year-old man who developed massive refractory CA post simultaneous pancreas-kidney (SPK) transplant. After conservative management with diet modifications failed, the patient underwent lymphangiography and lymph angioembolization using lipiodol. In this case report, we describe the use of lymphangiography as both a diagnostic and therapeutic approach to successfully manage large volume CA following SPK.
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Affiliation(s)
- Atta Nawabi
- The University of Kansas, Department of Surgery, 3901 Rainbow Blvd, M/S 2005, Kansas City, KS 66160, USA
| | - Adam C Kahle
- The University of Kansas, Department of Surgery, 3901 Rainbow Blvd, M/S 2005, Kansas City, KS 66160, USA
| | - Perel Baral
- The University of Kansas, Department of Surgery, 3901 Rainbow Blvd, M/S 2005, Kansas City, KS 66160, USA
| | - Clay D King
- Kansas City University, Kansas City, MO 64106, USA
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Saucedo-Crespo H, Roach E, Sakpal SV, Auvenshine C, Steers J. Spontaneous Chylous Ascites After Liver Transplantation Secondary to Everolimus: A Case Report. Transplant Proc 2020; 52:638-640. [PMID: 32029315 DOI: 10.1016/j.transproceed.2019.10.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 10/06/2019] [Indexed: 11/28/2022]
Abstract
Chylous ascites (CA) is an uncommon entity with several etiologies. Only a few cases of CA have been reported as a complication after liver transplantation (LT). Most of these cases occurred within 1 month after surgery and typically resulted from traumatic intraoperative injury leading to disruption of lymphatics. Although peripheral lymphedema has been frequently correlated with use of calcineurin inhibitors, associated spontaneous CA has only been reported in a few cases after renal transplantation. We report a case of delayed spontaneous CA after LT caused by the use of the mammalian target of rapamycin (mTOR) inhibitor everolimus. Everolimus was introduced in our patient early after transplantation because of tacrolimus-induced microangiopathy, and years later the patient presented with spontaneous CA. After excluding other causes of CA, everolimus was discontinued, and immunosuppression was maintained by increasing prednisone and continuing mycophenolate mofetil. Additionally, the patient was treated with percutaneous drain placement and began a low-fat, high-protein diet. One month later the patient had complete resolution of symptoms with no recurrence of ascites. To our knowledge, this is the first case of delayed-onset CA caused by everolimus after LT.
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Affiliation(s)
- Hector Saucedo-Crespo
- Avera McKennan Hospital & University Health Center, Avera Medical Group Transplant and Liver Surgery, Sioux Falls, South Dakota; Department of Surgery, University of South Dakota, Sanford School of Medicine, Sioux Falls, South Dakota.
| | - Eric Roach
- University of South Dakota, Sanford School of Medicine, Sioux Falls, South Dakota
| | - Sujit Vijay Sakpal
- Avera McKennan Hospital & University Health Center, Avera Medical Group Transplant and Liver Surgery, Sioux Falls, South Dakota; Department of Surgery, University of South Dakota, Sanford School of Medicine, Sioux Falls, South Dakota; Department of Internal Medicine, University of South Dakota, Sanford School of Medicine, Sioux Falls, South Dakota
| | - Christopher Auvenshine
- Avera McKennan Hospital & University Health Center, Avera Medical Group Transplant and Liver Surgery, Sioux Falls, South Dakota; Department of Surgery, University of South Dakota, Sanford School of Medicine, Sioux Falls, South Dakota
| | - Jeffery Steers
- Avera McKennan Hospital & University Health Center, Avera Medical Group Transplant and Liver Surgery, Sioux Falls, South Dakota
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10
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Two Cases of Atraumatic Chylous Ascites Characterized by Hypotriglyceridemia and Partially Managed with an Oral Fat-Free Elemental Diet. Case Rep Gastrointest Med 2020; 2020:7641476. [PMID: 31970002 PMCID: PMC6969991 DOI: 10.1155/2020/7641476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 08/01/2019] [Accepted: 08/13/2019] [Indexed: 11/19/2022] Open
Abstract
Most cases of chylous ascites occur after surgery, but it also develops in nonoperative cases, although rarely. Such cases are often difficult to treat. In this study, we treated 2 cases of atraumatic chylous ascites, which were controlled by combining diuretic treatment with an oral fat-free elemental diet (Elental®, EA Pharma Co., Ltd., Tokyo, Japan). Elental can provide oral nutrition compatible with a lipid-restricted diet, which may be useful for control of chylous ascites. We report on these cases, including literature review-based considerations.
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11
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Miserachs M, Lurz E, Levman A, Ghanekar A, Cattral M, Ng V, Grant D, Avitzur Y. Diagnosis, Outcome, and Management of Chylous Ascites Following Pediatric Liver Transplantation. Liver Transpl 2019; 25:1387-1396. [PMID: 31301267 PMCID: PMC7165704 DOI: 10.1002/lt.25604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 06/25/2019] [Indexed: 12/13/2022]
Abstract
Data on postoperative chylous ascites (CA) after pediatric liver transplantation (LT) are scarce. This retrospective study was conducted to identify the incidence, risk factors, management, and outcomes of postoperative CA in a large single-center pediatric LT cohort (2000-2016). The study cohort comprised 317 LTs (153 living donors and 164 deceased donors) in 310 recipients with a median age of 2.7 years. The incidence of CA was 5.4% (n = 17), diagnosed after a median time of 10 days after LT. Compared with chylomicron detection in peritoneal fluid (the gold standard), a triglyceride cutoff value of 187 mg/dL in peritoneal fluid showed insufficient sensitivity (31%) for CA diagnosis. In univariate logistic regression analyses, ascites before LT, younger age, and lower weight, height, and height-for-age z score at LT were associated with CA. Symptomatic management of CA included peritoneal drain (100%) and diuretics (76%). Therapeutic interventions included very low-fat or medium-chain triglyceride-rich diets (94%) and intravenous octreotide (6%), leading to CA resolution in all patients. CA was associated with prolonged hospital length of stay (LOS; 40 days in the CA group versus 24 days in the non-CA group; P = 0.001) but not with reduced patient or graft survival rates after a median follow-up time of 14 years. In conclusion, CA in the pediatric LT recipient is a relatively uncommon complication associated with increased hospital LOS and morbidity. Measurement of chylomicrons is recommended in patients with ascites that is more severe or persistent than expected. Dietary interventions are effective in most patients.
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Affiliation(s)
- Mar Miserachs
- Transplant and Regenerative Medicine CentreHospital for Sick ChildrenTorontoOntarioCanada
- Division of Pediatric Gastroenterology, Hepatology and NutritionHospital for Sick Children, University of TorontoTorontoOntarioCanada
- Universitat Autònoma de BarcelonaBellaterraSpain
| | - Eberhard Lurz
- Transplant and Regenerative Medicine CentreHospital for Sick ChildrenTorontoOntarioCanada
- Division of Pediatric Gastroenterology, Hepatology and Nutritionvon Haunersches Kinderspitak, Ludwig Maximillians University MunichMunichGermany
| | - Aviva Levman
- Transplant and Regenerative Medicine CentreHospital for Sick ChildrenTorontoOntarioCanada
| | - Anand Ghanekar
- Multi‐Organ Transplant ProgramUniversity Health NetworkTorontoOntarioCanada
- Department of SurgeryUniversity of TorontoTorontoOntarioCanada
| | - Mark Cattral
- Multi‐Organ Transplant ProgramUniversity Health NetworkTorontoOntarioCanada
- Department of SurgeryUniversity of TorontoTorontoOntarioCanada
| | - Vicky Ng
- Transplant and Regenerative Medicine CentreHospital for Sick ChildrenTorontoOntarioCanada
- Division of Pediatric Gastroenterology, Hepatology and NutritionHospital for Sick Children, University of TorontoTorontoOntarioCanada
| | - David Grant
- Multi‐Organ Transplant ProgramUniversity Health NetworkTorontoOntarioCanada
- Department of SurgeryUniversity of TorontoTorontoOntarioCanada
| | - Yaron Avitzur
- Transplant and Regenerative Medicine CentreHospital for Sick ChildrenTorontoOntarioCanada
- Division of Pediatric Gastroenterology, Hepatology and NutritionHospital for Sick Children, University of TorontoTorontoOntarioCanada
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Combined Chylothorax and Chylous Ascites Complicating Liver Transplantation: A Report of a Case and Review of the Literature. Case Rep Transplant 2019; 2019:9089317. [PMID: 31428509 PMCID: PMC6679892 DOI: 10.1155/2019/9089317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 07/04/2019] [Indexed: 12/03/2022] Open
Abstract
Chyle leaks may occur as a result of surgical intervention. Chyloperitoneum, or chylous ascites after liver transplantation, is rare and the development of chylothorax after abdominal surgery is even more rare. With increasingly aggressive surgical resections, particularly in the retroperitoneum, the incidence of chyle leaks is expected to increase in the future. Here we present a unique case of a combined chylothorax and chyloperitoneum following liver transplantation successfully managed conservatively. Risk factors for chylous ascites include para-aortic manipulation, extensive retroperitoneal dissection, use of a Ligasure device, and early enteral feeding as well as early enteral feeding. The clinical presentation is typically insidious and may include painless abdominal distension. Diagnosis can be made by noting characteristic milky white drainage which on laboratory examination has a total fluid triglyceride level >110 mg/dl, an ascites/serum triglyceride ratio of >1 and a leukocyte count in fluid >1000/uL with a lymphocyte predominance. Chyle leaks may lead to significant morbidity and mortality. Numerous management options exist, with conservative nonoperative measurements leading to the most consistent and successful outcomes. This includes a step-up approach beginning with dietary modifications to a low-fat or medium chain triglyceride diet followed by nil per os with addition of total parenteral nutrition and somatostatin analogues such as octreotide. Rarely do patients require more invasive treatment. Early recognition and appropriate management are imperative to mitigate this complication.
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13
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Sanampudi S, Krohmer S, Raissi D. Direct percutaneous embolization of intestinal lymphatic trunk for chylous ascites management following liver transplant. Radiol Case Rep 2019; 14:608-612. [PMID: 30899336 PMCID: PMC6409423 DOI: 10.1016/j.radcr.2019.02.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 02/20/2019] [Accepted: 02/23/2019] [Indexed: 12/23/2022] Open
Abstract
Chylous ascites can be caused by infection, trauma, malignancy, or maybe a complication after major abdominal surgery including liver transplantation. We present a case of a patient who developed chylous ascites following his liver transplantation. He was subsequently treated with direct embolization of lymphatic trunk efferent branches with a mixture of N-butyl cyanoacrylate and lipiodol after the identification of a localized leak on a fluoroscopic lymphangiogram. To our knowledge, this is the first reported case of chylous ascites following liver transplantation that was treated with direct embolization of intestinal lymphatic trunk branches.
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Affiliation(s)
- Sreeja Sanampudi
- University of Kentucky College of Medicine, 800 Rose St MN 150, Lexington, KY, 40536 USA.,University of Kentucky, Department of Radiology, 800 Rose St, Lexington, KY, 40536 USA
| | - Steven Krohmer
- University of Kentucky, Department of Radiology, 800 Rose St, Lexington, KY, 40536 USA
| | - Driss Raissi
- University of Kentucky, Department of Radiology, 800 Rose St, Lexington, KY, 40536 USA
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Abstract
BACKGROUND No protocol has been established for the diagnosis and management of chylous ascites after liver transplantation (LT). In this study, we retrospectively reviewed our cases of posttransplant chylous ascites (PTCA) and aimed to propose a diagnostic and management protocol. PATIENTS AND METHODS We retrospectively reviewed the clinical records of 96 LT recipients who underwent LT at our department. The incidence of PTCA and the associated risk factors were analyzed and our protocol for chylous ascites was evaluated. RESULTS PTCA occurred in 6 (6.3%) patients (mean age: 10.7±11.0years) at a mean of 10.8±3.6days after LT. The primary disease in all of PTCA cases was biliary atresia (BA). The periportal lymphadnopathy was an independent risk factor for PTCA. In all cases PTCA successfully resolved according to our protocol. Octreotide was administered in 4 of our 6 PTCA cases. The mean postoperative hospital stay was 40.2±8.4days, which was similar to that of cases without PTCA. CONCLUSIONS The incidence of PTCA in LT patients, especially in those with BA, is relatively high. Our diagnostic criteria and our management protocol were helpful for patients with refractory ascites after LT. TYPE OF STUDY Diagnostic test: Level II. Treatment study: Level III.
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15
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Lizaola B, Bonder A, Trivedi HD, Tapper EB, Cardenas A. Review article: the diagnostic approach and current management of chylous ascites. Aliment Pharmacol Ther 2017; 46:816-824. [PMID: 28892178 DOI: 10.1111/apt.14284] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 07/15/2017] [Accepted: 08/11/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND Chylous ascites is rare, accounting for less than 1% of cases. An appropriate and stepwise approach to its diagnosis and management is of key importance. AIM To review the current diagnostic approach and management of chylous ascites. METHODS A literature search was conducted using PubMed using the key words 'chylous', 'ascites', 'cirrhosis', 'pathophysiology', 'nutritional therapy', 'paracentesis", "transjugular intrahepatic portosystemic shunt" and "TIPSS'. Only articles in English were included. RESULTS Chylous ascites is caused by the traumatic or obstructive disruption of the lymphatic system that leads to extravasation of thoracic or intestinal lymph into the abdominal space and the accumulation of a milky fluid rich in triglycerides. The most common causes are malignancy, cirrhosis and trauma after abdominal surgery. This condition can lead to chyle depletion, which results in nutritional, immunologic and metabolic deficiencies. An ascitic triglyceride concentration above 200 mg/dL is consistent with chylous ascites. Treatment is based on management of the underlying cause and nutritional support. CONCLUSIONS Chylous ascites is mostly due to malignancy and cirrhosis in adults, and congenital lymphatic disorders in children. Treatment with nutritional optimization and management of the underlying etiology are the cornerstones of therapy. When conservative measures fail, other interventions such as octreotide/somatostatin analogues, surgical ligation, embolization and transjugular intrahepatic portosystemic shunt in patients with cirrhosis can be considered.
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Affiliation(s)
- B Lizaola
- Department of Medicine, St. Elizabeth Medical Center, Brighton, MA, USA
| | - A Bonder
- Liver Center, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - H D Trivedi
- Liver Center, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - E B Tapper
- Department of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - A Cardenas
- GI/Liver Unit, Institute of Digestive Diseases and Metabolism, University of Barcelona, Hospital Clinic and Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Barcelona, Spain
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16
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Yamada Y, Matsumoto S, Mori H, Takaji R, Kiyonaga M, Hijiya N, Tanoue R, Tomonari K, Tanoue S, Hongo N, Ohta M, Seike M, Inomata M, Murakami K, Moriyama M. Periportal lymphatic system on post-hepatobiliary phase Gd-EOB-DTPA-enhanced MR imaging in normal subjects and patients with chronic hepatitis C. Abdom Radiol (NY) 2017; 42:2410-2419. [PMID: 28444420 DOI: 10.1007/s00261-017-1155-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE We sought to evaluate visualization of periportal lymphatics and lymph nodes (lymphatic system) on Gd-EOB-DTPA-enhanced magnetic resonance (MR) images using a fat-suppressed T2-weighted sequence with 3-dimensional (3D) volume isotropic turbo spin echo acquisition (VISTA) at 3.0 T in normal subjects and patients with chronic hepatitis C. METHODS MR imaging was performed in 254 subjects between June 2013 and May 2016. After applying inclusion and exclusion criteria, the final population was 31 normal subjects and 34 patients with chronic hepatitis C. Images were acquired after the hepatobiliary phase following intravenous administration of Gd-EOB-DTPA, which causes signal loss in the bile ducts, to facilitate the visualization of the periportal lymphatic system. Two radiologists assessed the visualization of the periportal lymphatic system in 31 normal subjects. The axial dimensions of the main periportal lymphatic system in normal subjects were measured and compared with those of 34 patients with chronic hepatitis C using the Mann-Whitney U-test, and their correlation with a hepatic fibrosis marker, the Fibrosis-4 (FIB-4), was assessed using Spearman's rank correlation test. RESULTS The periportal lymphatic system was detected as high signal intensity areas surrounding the portal vein up to the third branches by each reader in all normal subjects. The axial dimensions of the main periportal lymphatic system in patients with chronic hepatitis C were significantly larger than those in normal subjects (p < 0.0001), and showed a significantly positive correlation with the FIB-4 score (ρ = 0.73, p < 0.001). CONCLUSIONS Fat-suppressed T2-weighted MR imaging with 3D-VISTA acquired after the hepatobiliary phase on Gd-EOB-DTPA-enhanced imaging may be a useful noninvasive method for evaluating the periportal lymphatic system and the degree of hepatic fibrosis.
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Affiliation(s)
- Yasunari Yamada
- Department of Radiology, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Shunro Matsumoto
- Department of Radiology, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan.
| | - Hiromu Mori
- Department of Radiology, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Ryo Takaji
- Department of Radiology, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Maki Kiyonaga
- Department of Radiology, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Naoki Hijiya
- Department of Molecular Pathology, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Rika Tanoue
- Oita Diagnostic Imaging Center, Beppu, Oita, 874-0023, Japan
| | | | - Shuichi Tanoue
- Department of Radiology, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Norio Hongo
- Department of Radiology, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Masayuki Ohta
- Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Masataka Seike
- Gastroenterology, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Masafumi Inomata
- Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Kazunari Murakami
- Gastroenterology, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
| | - Masatsugu Moriyama
- Department of Molecular Pathology, Oita University Faculty of Medicine, Yufu, Oita, 879-5593, Japan
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17
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Salsamendi JT, Gortes FJ, Mohan PP, Fan J, Narayanan G. Transjugular intrahepatic portosystemic shunt for chylous ascites in a patient with recurrent cirrhosis following liver transplantation. Radiol Case Rep 2017; 12:84-86. [PMID: 28228886 PMCID: PMC5310239 DOI: 10.1016/j.radcr.2016.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Accepted: 10/14/2016] [Indexed: 12/23/2022] Open
Abstract
Chylous ascites (CA) is the extravasation of lipid-rich lymphatic fluid into the peritoneal space following trauma or obstruction of the lymphatic system. Refractory cases of cirrhosis-related CA may be amendable to transjugular intrahepatic portosystemic shunting (TIPS). We present a case of TIPS in the setting of refractory CA secondary to cirrhosis of a transplanted liver graft. Following TIPS, the patient reported immediate improvement in abdominal pain and no longer requires paracentesis. Our case suggests TIPS to be a safe and effective treatment option for CA in liver transplant patients with cirrhosis.
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Affiliation(s)
- Jason T Salsamendi
- Department of Vascular Interventional Radiology, University of Miami Miller School of Medicine, 1611 NW 12th Ave, Miami, FL 33136-1005, USA
| | - Francisco J Gortes
- Department of Vascular Interventional Radiology, University of Miami Miller School of Medicine, 1611 NW 12th Ave, Miami, FL 33136-1005, USA
| | - Prasoon P Mohan
- Department of Vascular Interventional Radiology, University of Miami Miller School of Medicine, 1611 NW 12th Ave, Miami, FL 33136-1005, USA
| | - Ji Fan
- Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Govindarajan Narayanan
- Department of Vascular Interventional Radiology, University of Miami Miller School of Medicine, 1611 NW 12th Ave, Miami, FL 33136-1005, USA
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18
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Lee SY, Kim CH, Kim YJ, Kim HR. Chylous ascites after colorectal cancer surgery: risk factors and impact on short-term and long-term outcomes. Langenbecks Arch Surg 2016; 401:1171-1177. [PMID: 27553111 DOI: 10.1007/s00423-016-1500-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 08/16/2016] [Indexed: 12/14/2022]
Abstract
PURPOSE Data on the incidence, risk factors, and oncologic impact of chylous ascites after colorectal cancer surgery are scarce. In this study, we aimed to assess the risk factors and the short-term and long-term impact of chylous ascites after colorectal cancer surgery. METHODS We retrospectively examined 2917 primary colorectal cancer patients who underwent surgical resection between January 2008 and December 2013. The short-term and long-term outcomes were compared between patients with and those without postoperative chylous ascites, and the risk factors for chylous ascites were analyzed. RESULTS Chylous ascites developed in 138 (4.7 %) patients. A shorter operative time (odds ratio [OR] 0.992, 95 % confidence interval [CI] 0.988-0.996) and the number of retrieved lymph nodes (OR 1.015, 95 % CI 1.004-1.025) were independent risk factors for postoperative chylous ascites. All patients with chylous ascites were managed conservatively, without surgical intervention. The postoperative hospital stay was similar between the two groups (9.4 vs. 9.2 days, p = 0.467). After a median follow-up of 37 months (range 0-118 months), no significant difference was observed in the 3-year disease-free survival (85.0 vs. 83.9 %, p = 0.408) and 5-year overall survival (93.0 vs. 89.7 %, p = 0.662) between the two groups. CONCLUSIONS A major drawback of this study was that the definition of chylous ascites was solely based on clinical signs. Nevertheless, we can conclude that chylous ascites after colorectal cancer surgery is associated with a shorter operative time and the number of retrieved lymph nodes, but is not associated with the short-term and long-term outcomes.
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Affiliation(s)
- Soo Young Lee
- Department of Surgery, Chonnam National University Hwasun Hospital and Medical School, 322 Seoyang-ro Hwasun-eup, Hwasun-gun Jeonnam, Gwangju, 58128, South Korea
| | - Chang Hyun Kim
- Department of Surgery, Chonnam National University Hwasun Hospital and Medical School, 322 Seoyang-ro Hwasun-eup, Hwasun-gun Jeonnam, Gwangju, 58128, South Korea
| | - Young Jin Kim
- Department of Surgery, Chonnam National University Hwasun Hospital and Medical School, 322 Seoyang-ro Hwasun-eup, Hwasun-gun Jeonnam, Gwangju, 58128, South Korea
| | - Hyeong Rok Kim
- Department of Surgery, Chonnam National University Hwasun Hospital and Medical School, 322 Seoyang-ro Hwasun-eup, Hwasun-gun Jeonnam, Gwangju, 58128, South Korea.
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19
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Ilhan E, Demir U, Alemdar A, Ureyen O, Eryavuz Y, Mihmanli M. Management of high-output chylous ascites after D2-lymphadenectomy in patients with gastric cancer: a multi-center study. J Gastrointest Oncol 2016; 7:420-5. [PMID: 27284475 DOI: 10.21037/jgo.2016.02.03] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND This study aimed to propose treatment strategies for high-output chylous ascites (CA) developed after gastric cancer surgery. METHODS The data of patients with CA after gastric cancer surgery in three high volume Training and Research Hospitals between 2005 and 2015 were retrospectively evaluated. RESULTS Nine patients out of 436 gastrectomies were detected with CA. The mean amount of daily fistula output was 939 mL. Treatment consisted of cessation of oral feeding, total parenteral nutrition (TPN), somatostatin analogs administration, clamping and/or removal of the drainage tube, diuretic administration and diet therapy with medium-chain triglycerides (MCTs) alone or in combination. The mean fistula closure time and length of hospital stay were 23 and 24 days respectively. Hemopneumothorax developed during right subclavian vein catheterisation for TPN implementation in one patient. There was no mortality. CONCLUSIONS Combined cessation of oral feeding and TPN are usually used for treatment of CA as first-line treatment. However, TPN is no harmless. Although our data are limited they do allow us to conclude that diet with MCT's may use for medical treatment of CA as first-line.
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Affiliation(s)
- Enver Ilhan
- 1 Department of General Surgery, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey ; 2 Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey ; 3 Department of General Surgery, Okmeydani Training and Research Hospital, Istanbul, Turkey
| | - Uygar Demir
- 1 Department of General Surgery, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey ; 2 Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey ; 3 Department of General Surgery, Okmeydani Training and Research Hospital, Istanbul, Turkey
| | - Ali Alemdar
- 1 Department of General Surgery, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey ; 2 Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey ; 3 Department of General Surgery, Okmeydani Training and Research Hospital, Istanbul, Turkey
| | - Orhan Ureyen
- 1 Department of General Surgery, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey ; 2 Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey ; 3 Department of General Surgery, Okmeydani Training and Research Hospital, Istanbul, Turkey
| | - Yavuz Eryavuz
- 1 Department of General Surgery, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey ; 2 Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey ; 3 Department of General Surgery, Okmeydani Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Mihmanli
- 1 Department of General Surgery, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey ; 2 Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey ; 3 Department of General Surgery, Okmeydani Training and Research Hospital, Istanbul, Turkey
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20
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Piña-Pedraza J, Álvarez-Avalos L, Vargas-Espinosa J, Salcedo-Gómez A, Carranza-Madrigal J. Chylous ascites secondary to cirrhosis of the liver: A case report. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2015. [DOI: 10.1016/j.rgmxen.2015.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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21
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Piña-Pedraza JP, Álvarez-Avalos L, Vargas-Espinosa JM, Salcedo-Gómez A, Carranza-Madrigal J. Chylous ascites secondary to cirrhosis of the liver: A case report. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2015; 80:285-7. [PMID: 26298450 DOI: 10.1016/j.rgmx.2015.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 04/08/2015] [Accepted: 04/24/2015] [Indexed: 02/07/2023]
Affiliation(s)
- J P Piña-Pedraza
- Servicio de Medicina Interna, Hospital General «Dr. Miguel Silva» Secretaria de Salud, Morelia Michoacán, México
| | - L Álvarez-Avalos
- Servicio de Medicina Interna, Hospital General «Dr. Miguel Silva» Secretaria de Salud, Morelia Michoacán, México; Universidad Michoacana de San Nicolás de Hidalgo, Morelia Michoacán, México.
| | - J M Vargas-Espinosa
- Servicio de Medicina Interna, Hospital General «Dr. Miguel Silva» Secretaria de Salud, Morelia Michoacán, México
| | - A Salcedo-Gómez
- Servicio de Medicina Interna, Hospital General «Dr. Miguel Silva» Secretaria de Salud, Morelia Michoacán, México
| | - J Carranza-Madrigal
- Servicio de Medicina Interna, Hospital General «Dr. Miguel Silva» Secretaria de Salud, Morelia Michoacán, México
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22
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Weniger M, D'Haese JG, Angele MK, Kleespies A, Werner J, Hartwig W. Treatment options for chylous ascites after major abdominal surgery: a systematic review. Am J Surg 2015; 211:206-13. [PMID: 26117431 DOI: 10.1016/j.amjsurg.2015.04.012] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 04/01/2015] [Accepted: 04/17/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chylous leakage is a relevant clinical problem after major abdominal surgery leading to an increased length of stay. DATA SOURCES A systematic search of MEDLINE/PubMed and the Cochrane Library was performed according to the PRISMA statement. The search for the MeSH terms "chylous ascites" and/or "lymphatic fistula" retrieved a total of 2,348 articles, of which 36 full-text articles were reviewed by 2 independent investigators. RESULTS Chylous ascites is described with an incidence of up to 11%, especially after pancreatic surgery. The incidence is increasing with the number of lymph nodes harvested. In patients treated with total parenteral nutrition, conservative treatment is demonstrated to be effective in up to 100% of cases. CONCLUSIONS The extent of abdominal surgery mainly predicts the risk of chylous ascites. Conservative treatment has been shown to be effective in almost all cases and is the treatment of choice.
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Affiliation(s)
- Maximilian Weniger
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Campus Grosshadern, Ludwig-Maximilians-University, Marchioninistraße 15, Munich, D-81377, Germany
| | - Jan G D'Haese
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Campus Grosshadern, Ludwig-Maximilians-University, Marchioninistraße 15, Munich, D-81377, Germany
| | - Martin K Angele
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Campus Grosshadern, Ludwig-Maximilians-University, Marchioninistraße 15, Munich, D-81377, Germany.
| | - Axel Kleespies
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Campus Grosshadern, Ludwig-Maximilians-University, Marchioninistraße 15, Munich, D-81377, Germany
| | - Jens Werner
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Campus Grosshadern, Ludwig-Maximilians-University, Marchioninistraße 15, Munich, D-81377, Germany
| | - Werner Hartwig
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, Campus Grosshadern, Ludwig-Maximilians-University, Marchioninistraße 15, Munich, D-81377, Germany
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23
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Lu J, Wei ZQ, Huang CM, Zheng CH, Li P, Xie JW, Wang JB, Lin JX, Chen QY, Cao LL, Lin M. Small-volume chylous ascites after laparoscopic radical gastrectomy for gastric cancer: Results from a large population-based sample. World J Gastroenterol 2015; 21:2425-2432. [PMID: 25741151 PMCID: PMC4342920 DOI: 10.3748/wjg.v21.i8.2425] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 10/02/2014] [Accepted: 10/21/2014] [Indexed: 02/07/2023] Open
Abstract
AIM: To report the incidence and potential risk factors of small-volume chylous ascites (SVCA) following laparoscopic radical gastrectomy (LAG).
METHODS: A total of 1366 consecutive gastric cancer patients who underwent LAG from January 2008 to June 2011 were enrolled in this study. We analyzed the patients based on the presence or absence of SVCA.
RESULTS: SVCA was detected in 57 (4.17%) patients, as determined by the small-volume drainage (range, 30-100 mL/24 h) of triglyceride-rich fluid. Both univariate and multivariate analyses revealed that the total number of resected lymph nodes (LNs), No. 8 or No. 9 LN metastasis and N stage were independent risk factors for SVCA following LAG (P < 0.05). Regarding hospital stay, there was a significant difference between the groups with and without SVCA (P < 0.001). The 3-year disease-free and overall survival rates of the patients with SVCA were 47.4% and 56.1%, respectively, which were similar to those of the patients without SVCA (P > 0.05).
CONCLUSION: SVCA following LAG developed significantly more frequently in the patients with ≥ 32 harvested LNs, ≥ 3 metastatic LNs, or No. 8 or No. 9 LN metastasis. SVCA, which was successfully treated with conservative management, was associated with a prolonged hospital stay but was not associated with the prognosis.
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Chen JH, Chang CM, Lu MC, Wei CK, Yin WY. Delayed-Onset Chylous Ascites After a Living-Donor Liver Transplant: First Case Successfully Treated With Conservative Treatment? EXP CLIN TRANSPLANT 2014; 14:345-8. [PMID: 25365187 DOI: 10.6002/ect.2014.0131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Chylous ascites is a rare complication in liver transplant. Few cases have been reported to date. In most cases, chylous ascites is diagnosed within 1 month after surgery because of intraoperative injury of the hilar lymphatic system. Preoperative massive ascites and use of a LigaSure vessel sealing system for hilar dissection have been reported as risk factors. We report a case of chylous ascites after a living-donor liver transplant that was diagnosed after 6 months of uneventful follow-up. Sirolimus was added to cyclosporine early (2 wk after the operation) owing to poor renal function and it was found to be high (> 22 ng/mL) when the chylous ascites occurred. The patient was treated with total parenteral nutrition in combination with Sandostatin and rapid tapering of sirolimus after the failed initial conservative treatment. Residual abdominal fullness after meals and lymphedema of the legs disappeared 1 month after discontinuing sirolimus. This is the first case of delayed-onset chylous ascites after a liver transplant that was successfully treated conservatively.
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Affiliation(s)
- Jian-Han Chen
- From the Department of General Surgery, Dalin Tzu Chi General Hospital, Chia-I, Taiwan
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25
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Ünlüsoy Aksu A, Demirtaş Z, Eğritaş Gürkan Ö, Dalgıç B, Sözen H, Dalgıç A. Chylous ascites after a living-donor liver graft, effectively treated in a child with octreotide. EXP CLIN TRANSPLANT 2014; 12 Suppl 1:173-174. [PMID: 24635821 DOI: 10.6002/ect.25liver.p48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
Chylous ascites after a liver transplant is a rare complication of surgery. We report a 11-month-old girl with biliary atresia who was presented with chylous ascites after a liver transplant. On the seventh day after surgery, while being fed, chylous ascites was observed. Besides fasting and diuretics, total parenteral nutrition and somatostatin analogue (octreotide) were initiated. Chylous ascites resolved in 3 weeks. Abdominal distention recurred 1 week later; fasting and total parenteral nutrition, combined with octreotide, were administered again for 2 more weeks. Thereafter, enteral feeding was started without any complications.
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Affiliation(s)
- Aysel Ünlüsoy Aksu
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Gazi University, Ankara, Turkey
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