Chylous ascites following radical nephrectomy: efficiency of octreotide as treatment of a ruptured thoracic duct

Conservative management of chylous leak after open radical nephrectomy in an adult patient: a case report and literature review

Background

Chylous ascites is rare but still a recognized complication of retroperitoneal surgeries caused mostly by inadvertent trauma to lymphatic channels. In this article, we present a case report and literature review of adult patient, with malignant tumor of upper urinary tract, who developed chylous leak after open nephrectomy.

Case presentation

We present a case of chylous leak for a 67-year-old female patient, presented to urology clinic with complaining of left loin pain and gross hematuria, found to have upper urinary tract tumor, she underwent open radical nephrectomy with lymph nodes dissection, and postoperatively she had chylous leak that is treated conservatively using octreotide and spironolactone without the need for total parenteral nutrition.

Conclusion

Conservative management should always be the first choice of management of chylous leak and chylous ascites. Careful anatomical identification and securing of the periaortic lymphatics are needed to decrease the risk of postoperative chylous leak and ascites.

Chyle leak following surgery for abdominal neuroblastoma

BACKGROUND

The incidence and optimal management of postoperative chylous leak of neuroblastoma is inadequately documented. We analyzed the risk factors, management, and the implication of chyle leak following surgery for abdominal neuroblastoma.

METHODS

One hundred sixty patients who underwent surgery for abdominal neuroblastoma between September 2004 and August 2014 were evaluated. To find the oncological implication we evaluated the delay in starting further treatment, local control, event free and overall survival.

RESULTS

Chyle leak was the most common complication (20%). The median measure of leakage was 100ml/day and it persisted for a median of 12days. All patients were managed conservatively except one who needed exploration for wound dehiscence. Number of lymph nodes resected was the only factor associated with the risk of chyle leaks (p=0.013). Adjuvant chemotherapy was not delayed in any patient because of chyle leaks per se and the local control, event free and overall survival were not different for patients with and without chyle leak.

CONCLUSION

Chylous leakage is a common postoperative complication of abdominal neuroblastoma, predisposed by the number of lymph nodes resected. It responds to conservative management and does not compromise further the oncological treatment and outcome hence; it should not be a deterrent to complete surgery.

Chyle leak following right axillary lymph node dissection: A case report and review of current literature

•

Chyle leak is an uncommon complication of axillary node dissection.

•

The majority of reported cases occur on the left side, however several instances of right sided chyle leaks are reported.

•

The majority of chyle leaks respond to conservative management with: diet modification, pressure and drainage.

•

Diagnosis is based on clinical appearance for drainage, laboratory evaluation and lymphscintigraphy.

This report discusses the case of a chyle leak following a right axillary lymph node dissection for breast cancer. This presented as a sudden change in drainage character from a right axillary surgical drain from serous to milky white shortly after restarting a diet. The diagnosis of chyle leak was confirmed by laboratory testing of the fluid and managed with closed suction drainage. Chyle leak is a rare, but increasingly recognized complication following axillary clearance for breast cancer and melanoma.

Chylous ascites after laparoscopic donor nephrectomy

INTRODUCTION

The aim of this study was to determine the incidence, presentation, management, and outcomes of chylous ascites following laparoscopic donor nephrectomy.

METHODS

An Internet-based, multi-institutional survey was performed using http://www.surveymonkey.com. An email invitation to the voluntary survey was sent to 30 transplant centers and posted on CenterSpan, an email forum for transplant surgeons. The number of living donor transplantations and the number of cases of chylous ascites with clinical information, treatment and outcomes were sought from the questionnaire.

RESULTS

A total of 12 centers responded and reported 7683 cases of live donor nephrectomy. The reported incidence of postoperative chylous ascites was 0.013% (n = 12). Six centers reported 10 cases of chylous ascites following laparoscopic donor nephrectomy and 2 cases after open donor nephrectomy. Among the eight patients who developed chylous ascites following laparoscopic donor nephrectomy, presentation was typically 2 weeks after the date of initial surgery. Conservative therapy was successful in 50% of cases. Refractory ascites managed secondarily with surgical intervention had a success rate of 100%.

CONCLUSION

Chylous ascites is a rare complication following laparoscopic donor nephrectomy. Initial treatment should be conservative, with surgical therapy reserved for refractory cases.

[Octreotide treatment for postoperative chylous ascites in an adult]

Chylous ascites is infequent after abdominal surgery. We describe the case of a 43-year-old man with portal cavernomatosis who underwent surgery to insert a splenorenal shunt, which was not placed due to the absence of signs of portal hypertension. On postoperative day 20, the patient developed abdominal distension and mild dyspnea and was diagnosed with chylous ascites, which was related to the surgery. The patient was initially treated with diet and diuretics, with no clinical response, and consequently octreotide therapy was started. Four days later, the ascites was almost resolved and an ultrasound scan at 4 months showed its complete disappearance. This article demonstrates the effectiveness of octreotide in the treatment of postsurgical chylous ascites.

Chylous ascites as a complication of laparoscopic nephrectomy

PURPOSE

Chylous ascites is a rare complication after major retroperitoneal surgery. Recently chylous ascites has developed more often after laparoscopic nephrectomy since that is increasingly done for various indications at many centers. We reviewed our cases of chylous ascites after laparoscopic nephrectomy.

MATERIALS AND METHODS

Between January 2002 and December 2008 we performed 622 transperitoneal laparoscopic nephrectomies. We retrospectively analyzed factors related to chylous ascites as a complication of laparoscopic nephrectomy.

RESULTS

The overall incidence of chylous ascites was 5.1% (32 of 622 cases), including 4 severe refractory cases (0.6%). The difference in incidence by operation type was not statistically different (p = 0.251). Chylous ascites developed more often after left than right nephrectomy (7.3% or 25 of 343 cases vs 2.5% or 7 of 279, p = 0.010). In patients with radical nephrectomy and nephroureterectomy the incidence was higher in those who did vs did not undergo lymphadenectomy (13.9% or 10 of 72 vs 4.0% or 11 of 275, p = 0.027). Only 1 patient underwent explorative laparotomy due to persistent severe chylous ascites despite 8-week conservative management. The other cases were successfully managed conservatively by total parenteral nutrition and a low fat diet.

CONCLUSIONS

Chylous ascites is not a rare complication after laparoscopic nephrectomy and most cases can be managed conservatively. To prospectively prevent this complication we recommend meticulous clipping of all perihilar and retroperitoneal fibrous fatty tissue during major vessel dissection, especially for left nephrectomy or extensive lymphadenectomy.

The effectiveness of the treatment of octreotide on chylous ascites after liver cirrhosis

Octreotide is a crucial drug used for treating patients with chylous ascites; however, there have been few reports related to octreotide that are being used in cirrhotic patients. Thus, this thesis is designed to determine the effects of octreotide on patients with chylous ascites after liver cirrhosis. Eight patients were diagnosed with chylous ascites, on the basis of laboratory findings on ascites samples, between January 2003 and May 2008. Octreotide was given to the six patients, while the remaining two were treated as a control. All patients had persistent peritoneal drainage with the quantity and quality of the drainage fluid observed once every other day. All the necessary care was individually given to the patients during the therapy. All patients properly received combined therapy including a low-fat and low-sodium diet, and diuretic and peritoneal drainage. The volume of the peritoneal drainage was reduced to zero in one of the six patients who received octreotide therapy, while the other five had the drainage volumes decreased from 2,000 to 50 ml with a clear appearance and negative qualitative analysis of chyle. For those two patients who did not receive octreotide therapy, the conditions of peritoneal drainage seldom changed both from the qualitative and quantitative aspects. In conclusion, Octreotide, along with combined therapy, can rapidly relieve portal hypertension and reduce triglyceride levels in ascites. It appears to be an effective therapy available for the treatment of chylous ascites caused by liver cirrhosis.

Histiocytic sarcoma presenting with chylous ascites in a 7-month-old infant: a case report

We describe in this report what we believe to be the first report of a rare presentation of a very rare tumor, especially in this age group. We highlight the importance of early consideration of malignancy as a cause of chylous ascites in infancy and we discuss different causes of chylous ascites.

Chyloperitoneum Following Abdominal Aortic Surgery

Chyloperitoneum is an uncommon but serious complication following abdominal aortic surgery. As there seems to be no uniformity concerning the treatment, we performed a literature search to evaluate the best treatment results. All Medline-cited articles on chyloperitoneum after abdominal aortic surgery were assessed and analyzed. Thirty-eight cases of chyloperitoneum following abdominal aortic surgery were found. Patients developed symptoms after a median of 16 days (range 2–120 days) and were asymptomatic after 68 days (mean, range 27–93 years). All patients underwent diagnostic paracentesis, which confirmed the diagnosis. In 26 cases (68%), paracentesis was part of the treatment. The use of diuretics (24%) as therapeutic value was abandoned. Total parenteral nutrition, used in 21 patients (55%), provides the possibility of an extended period of oral starvation that reduces the lymphatic flow from the leaking duct. Medium-chain triglyceride, used in 28 cases (76%), is generally accepted as reducing lymphatic flow. When all conservative measures fail, surgical exploration is indicated. Two surgical interventions were mentioned: placing a peritoneovenous shunt or transfixing the damaged lymph vessel; both were described with different outcomes. This review supports conservative treatment of chyloperitoneum following abdominal aortic surgery.

Six cases of chylous leakage after axillary lymph node dissection

BACKGROUND

Chylous leakage has been described after several surgical procedures, especially in the region of the neck and thorax. However, it has rarely been reported after axillary lymph node dissection.

PATIENTS AND METHODS

We encountered 6 cases of chylous leakage after axillary lymph node dissection out of a total of 882 breast cancer patients between July 2005 and June 2007 in Shandong Provincial Hospital. These 6 cases were confirmed by axillary white fluid and chylomicron interpretation. The patients were treated conservatively, including a low fat diet, compression bandage, and suction drainage.

RESULTS

All 6 cases were successfully treated without any complications such as infection, dystrophy, and lymphoceles. The chylous leakage disappeared within a median of 5 days (range: 3-7 days). Adjuvant chemotherapy and radiotherapy were not delayed. After a median follow-up period of 12 months (range: 6-20 months), no chronic complications were observed.

CONCLUSION

Chylous leakage after axillary lymph node dissection is quite rare. It can be cured by conservative treatment. Lymphatic vessels should be identified carefully, and the main duct should be carefully ligated during surgical procedures, especially when level II and III lymph nodes are removed.

Chylous ascites after radical nephrectomy and inferior vena cava thrombectomy. Successful conservative management with somatostatin analogue

Postoperative chylous ascites is a rare complication of retroperitoneal surgery. The treatment of postoperative chylous ascites is primarily conservative, consisting of repeated paraceteses, medium chain triglyceride (MCT) diet, salt restriction, diuretics and bowel rest with total parenteral nutrition. Occasionally, chylous ascites may take a protracted course which may necessitate insertion of peritoneo-venous shunts or direct surgical lymphostasis. Recently, Somatostatin was shown to be highly effective in closure of refractory lymphatic fistulas. We present a case of refractory chylous ascites following radical nephrectomy with inferior vena caval thrombectomy that failed to respond to conventional conservative measures and resolved rapidly following the administration of Somatostatin.