Chylous ascites following retroperitoneal lymphadenectomy in gynecologic malignancies: Incidence, risk factors and management

Postoperative Chylous Ascites in Gynecological Malignancies: Two Case Reports and a Literature Review

Aim

To explore the potential factors that influence the presentation and recovery of postoperative chylous ascites (CA) in gynecological malignancies.

Methods

We reported two cases of postoperative CA following gynecological surgery and reviewed the clinical features of 140 patients from 16 relevant papers. Patients' clinicopathological characteristics, surgical approach, and management were summarized. The onset and resolution times of postoperative CA in different groups were analyzed separately.

Results

The two patients in our report had recovery after conservative treatments. According to the literature review, the median time of onset of postoperative CA was 5 days (range, 0-75 days) after surgery. The median resolution time was 9 days (range, 2-90 days). Among patients, 87.14% of them had lymphadenectomy during gynecological surgeries, while 92.86% of the patients had resolution after conservative treatments.

Conclusions

Lymphadenectomy during surgery may be relevant to the postoperative CA. Conservative management could be the initial choice for postoperative CA treatment.

Examination of the Usefulness of Standby Therapy for Refractory Chylous Ascites After Multiple Lymphangiography Interventions

Chylous ascites is infrequently observed following lymph node dissection in surgeries for gynecological malignancies. If symptoms develop, they can severely debilitate patients and increase the risk of infection, particularly those with a low performance status following the primary operation. Treatment of chylous ascites is often challenging and protracted, with no treatment currently guaranteeing a complete cure. This study explores the efficacy of standby therapy for refractory chylous ascites in a 46-year-old woman with gynecological malignancies who did not respond to multiple lymphangiographic interventions. Due to a suspicion of left ovarian cancer, she underwent surgery including lymph node dissection. On the following day, significant amounts of ascites were confirmed in the abdominal cavity. Despite performing lymphangiography twice, the chylous ascites persisted. During follow-up in the outpatient ward, on the 142nd post-surgery day, the ascites had spontaneously resolved. In cases like this, where symptoms are relatively mild and surgical intervention is not preferred due to complications or patient preference following lymphangiography, it may be beneficial to use standby therapy in combination with dietary management during outpatient follow-up. Such an approach could yield medium- to long-term improvements and should be considered. However, if further treatment is planned following the initial surgery, the patient's long-term prognosis should be considered, and treatment should be administered promptly. Various methods exist for treating refractory chylous ascites, including expectant therapy, dietary management, percutaneous drainage, lymphangiography and embolization, and surgical lymphatic ligation. Tailoring individualized treatment plans for each patient and pursuing a multidisciplinary approach is advisable. Although initiating adjuvant chemotherapy may not be feasible, long-term standby therapy is beneficial, even if lymphangiography proves ineffective in the short term.

Identifying safe diagnostic algorithms for sentinel lymph node mapping in high-risk endometrial cancer: The SENTIREC-endo study

INTRODUCTION

It is unclear if sentinel node (SLN) mapping can replace pelvic- (PLD) and paraaortic lymphadenectomy (PALD) for high-risk endometrial cancer (EC). A diagnostically safe surgical algorithm, taking failed mapping cases into account, is not defined. We aimed to investigate the diagnostic accuracy of SLN mapping algorithms in women with exclusively high-risk EC.

METHODS

We undertook a prospective national diagnostic cohort study of SLN mapping in women with high-risk EC from March 2017 to January 2023. The power calculation was based on the negative predictive value (NPV). Women underwent SLN mapping, PLD and PALD besides removal of suspicious and any FDG/PET-positive lymph nodes. Accuracy analyses were performed for five algorithms.

RESULTS

170/216 included women underwent SLN mapping, PLD and PALD and were included in accuracy analyses. 42/170 (24.7%) had nodal metastasis. The algorithm SLN and PLD in case of failed mapping, demonstrated a sensitivity of 86% (95% CI 74-100) and an NPV of 96% (95% CI 91-100). The sensitivity increased to 93% (95% CI 83-100) and the NPV to 98% (95% CI 94-100) if PLD was combined with removal of any PET-positive lymph nodes. Equivalent results were obtained if PLD and PALD were performed in non-mapping cases; sensitivity 93% (95% CI 83-100) and NPV 98% (95% CI 95-100).

CONCLUSION

SLN-mapping is a safe staging procedure in women with high-risk EC if strictly adhering to a surgical algorithm including removal of any PET-positive lymph nodes independent of location and PLD or PLD and PALD in case of failed mapping.

Chylous ascites following retroperitoneal lymphadenectomy in a patient with recurrent dysgerminoma of ovary: A case report

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.

Nomogram for predicting chylous ascites after right colectomy

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.

Prediction of prolonged resolution of chylous ascites after radical D3 resection for colorectal cancer: A population-based experience from a high-volume center

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.

Independent Risk Factors of Postoperative Lymphatic Leakage in Patients with Gynecological Malignant Tumor: A Single-Center Retrospective Study

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.

Intranodal Lymphangiography and Lymphatic Embolization for Management of Iatrogenic Chylous Ascites in Children

Background: To demonstrate the value of intranodal lymphangiography (INL) and lymphatic embolization (LE) in management of iatrogenic chylous ascites in children who fail conservative management. Methods and Results: Retrospective review of medical records revealed six patients (four males and two females; age range 11-39 months) who underwent eight INLs and three LEs between 2017 and 2019. In one patient, the leak was visualized and embolized. In three patients, the leak was not visualized and no embolization was done, but drain output decreased and INL was not repeated. In two patients, the leak was not visualized and no embolization was done, but drain output did not decrease and INL was repeated. Repeat INL identified a leak in one patient and targeted LE was done. Repeat INL did not identify a leak in the other patient, but empirical LE was performed at the sites suspicious for leakage after multidisciplinary discussion. INL was able to identify the site of lymphatic leak in two patients (33%). In the three patients who underwent LE (two targeted at the site of identified leak and one empirical at sites suspicious for leak), one (33%) was clinically successful and the other two required surgery to address the lymphatic leak. In three patients, chylous ascites resolved after INL alone with no additional interventions. Three patients developed complications after the procedure, but only one appears to be related to the procedure itself. Follow-up for 13.8 months (13-26 months) revealed no long-term complications or mortality. Conclusion: INL with or without LE is a safe treatment for iatrogenic pediatric chylous ascites. Early utilization before more invasive surgical intervention should be considered in light of the response to INL.

The retrospective research of enteral nutrition with medium-chain triglyceride and total parenteral nutrition support of postoperative chylothorax in adults

Background:

Chylothorax is caused by thoracic lymphatic system injuries that leads to the lymph extravasating into the thoracic cavity. There are few reports comparing the therapeutic effects of enteral nutrition with medium-chain triglyceride and total parenteral nutrition, and the results are inconsistent. Our study aimed to research the optimum nutrition support method for chylothorax.

Study design:

We retrospectively reviewed 35 chylothorax patients after heart and chest surgery from 2014 to 2018, at West China Hospital of Sichuan University, among them there were 27 post-heart surgery patients. We analyzed the therapeutic effects and costs of enteral nutrition with medium-chain triglyceride (E group) and total parenteral nutrition (T group) for chylothorax.

Results:

The results were similar in patients with all surgeries and patients with only post heart surgery. The total cost during hospitalization in E group was higher than T group (P < 0.01), whereas the nutrition support cost was lower (P < 0.001). The length of hospital stay was longer in E group than T group (P > 0.05). Time from admission to surgery was shorter and from surgery to chylothorax diagnosis was longer in E group compared with T group. Time to resolution and removal of drainage was shorter in E group than T group but the differences were not significant.

Conclusion:

The therapeutic effects in enteral nutrition with medium-chain triglyceride and total parenteral nutrition had no obvious differences. Moreover, enteral nutrition with medium-chain triglyceride is safer and more economical. Therefore, we suggest that enteral nutrition with medium-chain triglyceride could be the first choice to treat postoperative chylothorax when the gastrointestinal tract function is allowed, and this result could be considered for postoperative chylous ascites.

First Case of Chylous Ascites after Laparoscopic Myomectomy: A Case Report with a Literature Review

Introduction: Chylous ascites is a rare form of ascites characterized by milk-like peritoneal fluid, rich in triglycerides. Clinical signs and symptoms include abdominal distention, pain, nausea, and vomiting. In gynecology, the most common cause for its occurrence is lymph dissection leading to impairment of major lymphatic vessels. There are only a few reported cases of chylous ascites arising after operations for benign diseases. Case report: We report a case of a 46-year-old female patient, who underwent laparoscopy for a myomatous node with chylous ascites occurring on post-surgery Day 2. The ascites was conservatively managed. The exact cause of the chyloperitonitis could not be determined. Conclusion: Although extremely rarely, chylous ascites may also occur in operative interventions for benign diseases in gynecological surgery.

The role of oral oil administration in displaying the chylous tubes and preventing chylous leakage in laparoscopic para-aortic lymphadenectomy

BACKGROUND AND OBJECTIVES

This study is aimed to investigate the possibility of preoperative oral oil administration in displaying the chylous tubes and preventing chylous leakage in laparoscopic para-aortic lymphadenectomy.

MATERIALS AND METHODS

In this retrospective nonrandomized study, of the 30 patients with gynecological malignancies who had indications for laparoscopic para-aortic lymphadenectomy up to renal vessels, 15 were administered preoperative oral oil (oil a administration) (control group) at our hospital between September 2017 and June 2018. The chylous tube displaying rates, incidences of chylous leakage, and other perioperative data of the two groups were compared.

RESULTS

Successful display of chylous tubes was observed in 93.3% (14/15) patients in the oil administration group. The chylous leakage was zero in the oil administration group, and 33.3% (5/15) in the control group. The postoperative drainage duration (4.1 ± 1.0 days vs 7.6 ± 1.4 days, P = 0.000), somatostatin application time (0 day vs 5.9 ± 0.8 days), and postoperative hospital stay (6.0 ± 2.3 days vs 9.1 ± 2.1 days, P = 0.001) were significantly shorter in the oil administration group. The total cost is lower in the oil administration group (4972.52 ± 80.54 dollars vs 6260.80 ± 484.47 dollars, P = 0.000).

CONCLUSIONS

Preoperative oil administration is a feasible and effective method to display the chylous tubes and to prevent the chylous leakage in para-aortic lymphadenectomy.

Does BLOODCARE Powder Prevent Postoperative Chylous Ascites After Lymphadenectomy for Gynecological Malignancies?

OBJECTIVE

The aim of this study was to evaluate the effect of an intraoperative hemostatic cellulose agent (BLOODCARE powder [Life Line, Brno, Czech Republic]) on reducing the incidence of postoperative chylous ascites (PCA) after complete pelvic and para-aortic lymphadenectomy (PPALN) in patients with gynecological cancers treated with laparotomy.

METHODS

This case control study reviewed 150 patients with gynecological cancer who underwent PPALN. In the study group (n = 75), BLOODCARE powder was applied below the left renal vein and bilateral obturator fossa. In the control group (n = 75), no sealant agent was used after the procedure, such as fibrin glue or a hemostatic cellulose agent.

RESULTS

The demographic and surgical characteristics of the patients in both groups were similar. Chylous ascites occurred in 9 cases (6%). The incidence of PCA was lower in the study group (1 [1.3%] vs 8 [10.7%]; P = 0.03). Logistic regression analysis indicated that using BLOODCARE powder during the surgery independently protected against the development of PCA.

CONCLUSIONS

Using BLOODCARE powder during retroperitoneal surgery may prevent PCA. This simple, effective agent should be used after PPALN for gynecological cancers.

Extensive lymph node dissection during pancreaticoduodenectomy: a risk factor for hepatic steatosis?

PURPOSE

The first reports of hepatic steatosis following pancreaticoduodenectomy (PD) were published several years ago; however, clear risk factors remain to be identified. Therefore, the aim of this study was to identify the risk factors for hepatic steatosis post-PD.

METHODS

We studied 90 patients who had undergone PD between September 2005 and January 2015. The inclusion criteria were as follows: available unenhanced CT within one month before PD and at least one unenhanced CT acquisition between PD and chemotherapy initiation. Using scanners, we studied the liver and spleen density as well as the surface areas of visceral (VF) and subcutaneous fat (SCF). These variables were previously identified by univariate and multivariate analyses.

RESULTS

Hepatic steatosis occurred in 25.6% of patients at 45.2 days, on average, post-PD. Among the patients with hepatic steatosis, the average liver density was 52 HU before PD and 15.1 HU post-PD (p < 0.001). The Patients with hepatic steatosis lost more VF (mean, 28 vs. 11 cm²) and SCF (28.8 vs. 13.7 cm²) (p < 0.01 and p = 0.01, respectively). Portal vein resection and extensive lymph node dissection were independent risk factors in the multivariate analysis (odds ratio [OR] 5.29, p = 0.009; OR 3.38, p = 0.04, respectively).

CONCLUSION

Portal vein resection and extensive lymph node dissection are independent risk factors for post-PD hepatic steatosis.

Chylous Ascites Complicating Modified Radical Hysterectomy for Placenta Percreta

BACKGROUND

Chylous ascites is defined as the pathologic accumulation of lymphatic fluid within the peritoneal cavity and has been reported to complicate gynecologic surgeries, with an incidence of 0.17-2%. We report a case of chylous ascites after complex surgery for placenta percreta.

CASE

A 26-year-old woman underwent cesarean delivery followed by bilateral uterine artery embolization and modified radical hysterectomy at 26 5/7 weeks of gestation for placenta percreta invading the urinary bladder. No surgical dissection was performed above the pelvic brim or deep into the pelvic sidewalls. On postoperative day 4, milky fluid consistent with chylous ascites was noted coming from a percutaneous drain. This completely resolved after 12 days of conservative management with intravenous nutritional support.

CONCLUSION

Chylous ascites is a potential complication of modified radical hysterectomy for placenta percreta that responds to conservative management.