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Schmeusser BN, Palacios AR, Maithel S, Master VA. Response to a letter to the editor regarding inferior vena cava ligation. J Surg Oncol 2022; 126:1576-1577. [DOI: 10.1002/jso.27131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 11/12/2022]
Affiliation(s)
| | - Arnold R. Palacios
- Department of Urology Emory University School of Medicine Atlanta Georgia USA
| | - Shishir Maithel
- Department of Surgery Emory University School of Medicine Atlanta Georgia USA
| | - Viraj A. Master
- Department of Urology Emory University School of Medicine Atlanta Georgia USA
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Alrabadi A, Ihmeidan M, Al Demour S. Conservative management of chylous leak after open radical nephrectomy in an adult patient: a case report and literature review. AFRICAN JOURNAL OF UROLOGY 2021. [DOI: 10.1186/s12301-020-00116-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
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.
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Hargis PA, Henslee B, Pokala N, Bhat A. Percutaneous Lymphatic Maceration and Glue Embolization for High-output Chylous Ascites after Robot-assisted Laparoscopic Nephrectomy and Lymphadenectomy. J Clin Imaging Sci 2021; 11:56. [PMID: 34754596 PMCID: PMC8571355 DOI: 10.25259/jcis_100_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 10/14/2021] [Indexed: 11/26/2022] Open
Abstract
To propose minimally invasive percutaneous techniques in the management of high output chylous ascites, a known potential complication of retroperitoneal surgery associated with significant morbidity and mortality. Management has traditionally been based on successful treatment reported in the literature. However, refractory or high-output leaks often prove difficult to treat and there is little evidence on superior management. We report percutaneous maceration and embolization for the management of high-volume abdominal chyle leak after robot-assisted laparoscopic (RAL) radical nephrectomy and lymph node dissection for renal cell carcinoma. A 68-year-old male with incidentally found renal cell carcinoma underwent RAL radical nephrectomy with paraaortic lymph node dissection. He initially improved after surgery but developed significant abdominal pain and distension approximately 7 weeks postoperative. This proved to be chyloperitoneum. Conservative management was initiated, but after continued high-output (>1 L) fluid drainage, we pursued adjunct intervention involving Interventional Radiological percutaneous procedures. This included lymphatic maceration and glue embolization of leaking lymphatics. The patient tolerated the percutaneous procedures well with significant improvement in drain output ultimately leading to complete resolution of ascites without further complication. Similar interventions have previously been reported in the literature for cases of chylothorax with success. However, there is a lack of reports on utilizing this minimally invasive procedure for chyloperitoneum after retroperitoneal urologic surgery. We report our successful experience with percutaneous lymphatic maceration and embolization for high output chylous ascites after RAL radical nephrectomy with lymphadenectomy. We believe that early initiation utilizing these percutaneous techniques can achieve timely resolution and should be considered in the management of these patients.
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Affiliation(s)
- Paige Ashley Hargis
- School of Medicine, University of Missouri-Columbia, Columbia, Missouri, USA
| | - Brandon Henslee
- Department of Surgery, Division of Urology, University of Missouri-Columbia School of Medicine, Columbia, Missouri, USA
| | - Naveen Pokala
- Department of Surgery, Division of Urology, University of Missouri-Columbia School of Medicine, Columbia, Missouri, USA
| | - Ambarish Bhat
- Department of Radiology, Division of Interventional Radiology, University of Missouri-Columbia School of Medicine, Columbia, Missouri, USA
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Chu CF, Wu CT, Hsieh WC, Huang JJ. Management of intractable post-adrenalectomy chylous ascites with microsurgical intra-abdominal lymphaticovenous anastomosis: A case report and literature review. Microsurgery 2021; 41:480-487. [PMID: 33822407 DOI: 10.1002/micr.30740] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 03/15/2021] [Accepted: 03/26/2021] [Indexed: 12/11/2022]
Abstract
Postoperative chylous ascites is a rare but highly morbid complication following thoracic or abdominal surgeries. Treatment options vary according to different clinical scenarios and facility equipment, but there is no standard guideline. We report a case of 46-year-old patient with chylous ascites after left laparoscopic adrenalectomy for metastatic lung cancer. The conservative treatments failed, included diet control, somatostatin provided and intranodal lymphangiography with lipiodol injection. Laparotomy was performed to explore the lymphatic vessel in the retroperitoneal area where a major and several small leaking holes were identified along the thoracic duct. The left gonadal vein was explored and transposed toward the lymphatic vessel. The lymphaticovenous anastomosis (LVA) was done using side (major leaking hole) to end (gonadal vein) fashion. The chylous leakage dropped from 2000 to 200 mL per day gradually within 10 days after LVA, and the patient was discharged uneventfully 30 days after the LVA surgery. He was followed at our clinic during the first postoperative 10 months without recurrent chylous ascites. This case demonstrates that microsurgical intervention with LVA to physiologically drain the chyle can be an optimal treatment for chylous ascites. A literature review was also conducted, and strategic management is proposed.
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Affiliation(s)
- Cheng-Feng Chu
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chun-Te Wu
- Department of Urology, Chang Gung Memorial Hospital, Keelung, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wei-Chuan Hsieh
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Jung-Ju Huang
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,Center for Tissue Engineering, Chang Gung Memorial Hospital, Linkou, Taiwan
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Cupellini C, Alemanno G, Bottari A, Bella AD, Bruscino A, Martellucci J, Bergamini C, Pantalone D, Prosperi P. Laparosacopic management with combination of fatty meal and methylen-blu for chylous leak after a left para-aortic paraganglioma excision. J Surg Case Rep 2020; 2020:rjaa497. [PMID: 33408851 PMCID: PMC7771193 DOI: 10.1093/jscr/rjaa497] [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: 10/11/2020] [Accepted: 11/05/2020] [Indexed: 11/15/2022] Open
Abstract
We report a case of chylous leak recognized post-operatively after abdominal surgery for left para-aortic paraganglioma in a young female with a history of open botallo’s duct. Conservative measures failed to control the leak and the patient is not eligible for sclerotisation. Laparoscopic exploration with intralipidand methylen blue injection through an orogastric tube revealed the leaking area near the superior mesenteric vein behind the Traitz, and this was ligated with non-asorbable suture and placement of acrylic glue. The patient was discharged the 7th post-operative day after removal of the drainage which appeared to supply <100 cc of serum material. Outpatient control was successful and the patient is actually in good conditions.
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Affiliation(s)
- Curzio Cupellini
- Emergency Surgery Unit, Emergency Department, Careggi University Hospital, Florence, Italy
- Correspondence address. Via Romana 51, 50125 Firenze, Italy. Tel: +39 3386047239; Fax: +39 0558364410; E-mail:
| | - Giovanni Alemanno
- Emergency Surgery Unit, Emergency Department, Careggi University Hospital, Florence, Italy
| | - Andrea Bottari
- Emergency Surgery Unit, Emergency Department, Careggi University Hospital, Florence, Italy
| | - Annamaria Di Bella
- Emergency Surgery Unit, Emergency Department, Careggi University Hospital, Florence, Italy
| | - Alessandro Bruscino
- Emergency Surgery Unit, Emergency Department, Careggi University Hospital, Florence, Italy
| | - Jacopo Martellucci
- Emergency Surgery Unit, Emergency Department, Careggi University Hospital, Florence, Italy
| | - Carlo Bergamini
- Emergency Surgery Unit, Emergency Department, Careggi University Hospital, Florence, Italy
| | - Desiree Pantalone
- Emergency Surgery Unit, Emergency Department, Careggi University Hospital, Florence, Italy
| | - Paolo Prosperi
- Emergency Surgery Unit, Emergency Department, Careggi University Hospital, Florence, Italy
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Lymphangiography and Lymphatic Embolization for the Treatment of Refractory Chylous Ascites. Cardiovasc Intervent Radiol 2017; 41:415-423. [DOI: 10.1007/s00270-017-1856-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 12/05/2017] [Indexed: 12/23/2022]
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7
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Ng ZQ, He B. A Proposed Classification System and Therapeutic Strategy for Chyle Leak After Laparoscopic Living-Donor Nephrectomy: A Single-Center Experience and Review of the Literature. EXP CLIN TRANSPLANT 2017; 16:143-149. [PMID: 29108520 DOI: 10.6002/ect.2016.0305] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Chyle leak or chylous ascites remains a rare complication after laparoscopic living-donor nephrectomy. Its cause and management have not been well elucidated in the literature. Thus, the aim of this study was to review the incidence of chyle leak/chylous ascites after laparoscopic living-donor nephrectomy in our institute and in the literature to propose a classification system with its associated treatment strategy. MATERILAS AND METHODS In this retrospective review of laparoscopic living-donor nephrectomy patients from January 2005 to April 2016, we identified patients with chyle leak/chylous ascites along with the care performed. A proposed classification system based on our experience and literature is described. RESULTS Chylous leak developed in 4 donors (2.25%). Of the 4 donors, 3 were treated nonoperatively with diet modification and subcutaneous octreotide injection. One patient required surgical intervention after not responding to second-line therapy with total parenteral nutrition. CONCLUSIONS Chyle leak/chylous ascites after laparoscopic living-donor nephrectomy is rare, but a delayed diagnosis may lead to morbidity secondary to malnutrition and immunosuppression. Meticulous surgical dissection is essential to seal the lymphatic tubes during laparoscopic living-donor nephrectomy. The proposed classification system provides a practical and tailored guide to management based on the drainage volume of chyle leak and a guide to the earlier identification of refractory cases.
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Affiliation(s)
- Zi Qin Ng
- From the WA Liver and Kidney Transplant Service, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
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8
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A Large Pleural Effusion following Abdominal Aortic Surgery. Case Rep Pulmonol 2015; 2015:254010. [PMID: 26635989 PMCID: PMC4655280 DOI: 10.1155/2015/254010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 09/27/2015] [Indexed: 02/07/2023] Open
Abstract
Chylous ascites and coexistent chylothorax is a rare but important complication following retroperitoneal abdominal surgery. We report a 70-year-old male who developed gradual abdominal distension, chest tightness, and dyspnea five months after having an uncomplicated aortobifemoral bypass performed. Physical examination was consistent with a large right sided effusion and ascites which were confirmed by computed tomography. Thoracentesis yielded an opaque milky fluid with analysis consistent with a chylothorax with a paracentesis revealing fluid that was similar in both appearance and biochemistry. The patient failed initial conservative management so a chest tube was placed followed by chemical pleurodesis. We review the literature of the pathophysiology and treatment approach to such a pleural effusion.
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Jairath A, Singh A, Ganpule A, Mishra S, Sabnis R, Desai M. Management Protocol for Chylous Ascites After Laparoscopic Nephrectomy. Urology 2015. [PMID: 26210005 DOI: 10.1016/j.urology.2015.06.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To devise a management protocol for chylous ascites after laparoscopic nephrectomy. PATIENTS AND METHODS We retrospectively reviewed the data of the patients that underwent laparoscopic nephrectomy between January 2010 and January 2014 in our institution for different indications and were diagnosed with chylous ascites. We also analyzed a different management protocol that was used. RESULTS The overall incident rate of chylous ascites was 0.77%. It was more commonly seen on left side and with simple nephrectomy rather than radical. Three out of 9 patients were managed by surgical intervention, rest were successfully managed on conservative treatment in the form of dietary modification, total parenteral nutrition, or octreotide. CONCLUSION Chylous ascites is a rare but morbid condition following laparoscopic nephrectomy. To manage this complication, we propose preventive and treatment strategies based on symptoms and amount of chylous ascites using our experience and review of the literature.
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Affiliation(s)
- Ankush Jairath
- Department of Urology, Muljhibhai Patel Urological Hospital, Nadiad, Gujarat, India.
| | - Abhishek Singh
- Department of Urology, Muljhibhai Patel Urological Hospital, Nadiad, Gujarat, India
| | - Arvind Ganpule
- Department of Urology, Muljhibhai Patel Urological Hospital, Nadiad, Gujarat, India
| | - Shashikant Mishra
- Department of Urology, Muljhibhai Patel Urological Hospital, Nadiad, Gujarat, India
| | - Ravindra Sabnis
- Department of Urology, Muljhibhai Patel Urological Hospital, Nadiad, Gujarat, India
| | - Mahesh Desai
- Department of Urology, Muljhibhai Patel Urological Hospital, Nadiad, Gujarat, India
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10
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Hsiao CH, Yu CC, Hsieh TY, Kao YL, Wang SC, Chen WJ, Chen SL. Chylous ascites as a complication of nephroureterectomy. UROLOGICAL SCIENCE 2015. [DOI: 10.1016/j.urols.2015.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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11
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Montes SFP, Rodríguez IG, Ugarteburu RG, Villamil LR, Mendez BD, Gil PS, Madera JM. Intraoperative laparoscopic complications for urological cancer procedures. World J Clin Cases 2015; 3:450-456. [PMID: 25984519 PMCID: PMC4419108 DOI: 10.12998/wjcc.v3.i5.450] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 01/30/2015] [Accepted: 04/09/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To structure the rate of intraoperative complications that requires an intraoperative or perioperative resolution.
METHODS: We perform a literature review of Medline database. The research was focused on intraoperative laparoscopic procedures inside the field of urological oncology. General rate of perioperative complications in laparoscopic urologic surgery is described to be around 12.4%. Most of the manuscripts published do not make differences between pure intraoperative, intraoperative with postoperative consequences and postoperative complications.
RESULTS: We expose a narrative statement of complications, possible solutions and possible preventions for most frequent retroperitoneal and pelvic laparoscopic surgery. We expose the results with the following order: retroperitoneal laparoscopic surgery (radical nephrectomy, partial nephrectomy, nephroureterectomy and adrenalectomy) and pelvic laparoscopic surgery (radical prostatectomy and radical cystectomy).
CONCLUSION: Intraoperative complications vary from different series. More scheduled reports should be done in order to better understand the real rates of complications.
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Corradini S, Liebig S, Niemoeller OM, Zwicker F, Lamadé W. Successful radiation treatment of chylous ascites following pancreaticoduodenectomy. Strahlenther Onkol 2015; 191:448-52. [DOI: 10.1007/s00066-014-0805-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2014] [Accepted: 12/18/2014] [Indexed: 12/27/2022]
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13
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Xiu L, Yan B, Qin Z, Liu X, Wu F, Wang X, Wei P. Chylous ascites treated by traditional Chinese herbal medicine: a case report and discussion. Complement Ther Med 2014; 23:63-7. [PMID: 25637154 DOI: 10.1016/j.ctim.2014.10.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 08/13/2014] [Accepted: 10/03/2014] [Indexed: 10/24/2022] Open
Abstract
Chylous ascites, which can lead to peritonitis, intestinal obstruction, metabolic disorder, and even death from pyemia, is a rare complication of abdominal surgery. Currently, first-line treatment involves conservative management, which includes oral diet and total parenteral nutrition (TPN). However, the efficacy of these treatments cannot be guaranteed. For example, single diet control can result in consecutive drainage for up to 1 month, and salvage surgery is required for some invalid cases. Here, we report 6 cases of chylous ascites after abdominal surgery. In addition to diet control, we delivered traditional Chinese herbal medicine (TCHM) twice daily orally. The drainage volume of the chylous fistula showed an obvious decrease 1 day after the TCHM administration and all 6 patients completely recovered within 4 to 8 days (median: 5.5 days). Although relevant data are limited, our cases would suggest that TCHM could play an important role in the management of chylous ascites. However, randomized controlled trials are still needed to confirm its efficacy in a larger population.
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Affiliation(s)
- Lijuan Xiu
- Department of Traditional Chinese Medicine, Chang Zheng Hospital, the Second Military Medical University, Shanghai 200003, China
| | - Bing Yan
- Department of Traditional Chinese Medicine, Chang Zheng Hospital, the Second Military Medical University, Shanghai 200003, China
| | - Zhifeng Qin
- Department of Traditional Chinese Medicine, Chang Zheng Hospital, the Second Military Medical University, Shanghai 200003, China
| | - Xuan Liu
- Department of Traditional Chinese Medicine, Chang Zheng Hospital, the Second Military Medical University, Shanghai 200003, China
| | - Feng Wu
- Department of Traditional Chinese Medicine, Chang Zheng Hospital, the Second Military Medical University, Shanghai 200003, China
| | - Xiaowei Wang
- Department of Traditional Chinese Medicine, Chang Zheng Hospital, the Second Military Medical University, Shanghai 200003, China
| | - Pinkang Wei
- Department of Traditional Chinese Medicine, Chang Zheng Hospital, the Second Military Medical University, Shanghai 200003, China.
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Kim EA, Park H, Jeong SG, Lee C, Lee JM, Park CT. Octreotide therapy for the management of refractory chylous ascites after a staging operation for endometrial adenocarcinoma. J Obstet Gynaecol Res 2013; 40:622-6. [PMID: 24118223 DOI: 10.1111/jog.12183] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 05/11/2013] [Indexed: 11/27/2022]
Abstract
Chylous ascites after para-aortic lymphadenectomy is caused by a rupture in the retroperitoneal lymphatic channels. The incidence of postoperative chylous ascites is increasing as para-aortic lymphadenectomy for the management of gynecologic malignancies becomes more common. However, management of this condition remains unsatisfactory because some patients do not respond to conservative methods and have to undergo surgical intervention, even though they may be malnourished and immunosuppressed. We report the case of a patient who underwent a standard staging operation for endometrial cancer and experienced a large amount of lymphatic leakage, in spite of treatment with total parenteral nutrition and a low-fat diet for over 40 days. As a step-up approach, octreotide, a somatostatin analog, was added and the disease resolved completely. This case demonstrated that octreotide therapy is highly effective in refractory cases of chylous ascites where a large amount of leakage is observed and cases that are otherwise indicated for surgical intervention.
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Affiliation(s)
- Eun Ah Kim
- Comprehensive Gynecologic Cancer Center, CHA Bundang Medical Center, College of Medicine, CHA University, Seongnam-si, Korea
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Kim JK, Park JS, Hwang HK, Shin HW, Yoon DS. Drainage volume after pancreaticoduodenectomy is a warning sign of chyle leakage that inversely correlates with a diagnosis of pancreatic fistula. World J Surg 2013; 37:854-62. [PMID: 23389668 DOI: 10.1007/s00268-013-1919-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Chyle leakage is a rare complication of pancreaticoduodenectomy (PD), and its association with pancreatic fistula has not been established. The aim of this study was to (1) evaluate the incidence, management, and risk factors of chyle leakage after PD; (2) determine if there is a relation between chyle leakage and diagnosis of pancreatic fistula; and (3) predict chyle leakage with drainage volume early. METHODS A total of 222 patients underwent PD or pylorus-preserving PD. We used the clinical database registry system of the Gangnam Severance Hospital, Yonsei University Health System to establish a retrospective cohort with clinicopathologic data. RESULTS Altogether, 24 patients (10.8 %) developed chyle leakage. Chyle leakage was identified at a median 5 days after surgery and a mean 2 days after enteral intake. The mean drain triglyceride level was 315 mg/dl. Early enteral intake was independently associated with chyle leakage. Chyle leakage was inversely correlated with a diagnosis of pancreatic fistula with marginal significance (odds ratio 0.27; 95 % confidence interval 0.66-1.09). The receiver operating characteristic curve of the volume on postoperative day 4 demonstrated an area under the curve of 0.740 (p = 0.0001). Drainage >335 ml indicated possible chyle leakage. CONCLUSIONS Chyle leakage after PD is associated with early enteral intake. It was inversely correlated with a diagnosis of pancreatic fistula because of the dilution effect of drainage volume on the concentration of drained amylase. Because early diagnosis helps with appropriate management, prediction/suspicion of chyle leakage based on drainage volume may be useful.
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Affiliation(s)
- Jae Keun Kim
- Pancreatobiliary Cancer Clinic, Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eunjoro Gangnam-gu, Seoul, 135-720, South Korea
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Re: "Chylous ascites: analysis of 24 patients". Gynecol Oncol 2012; 127:435-6. [PMID: 22841874 DOI: 10.1016/j.ygyno.2012.07.108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 07/17/2012] [Indexed: 11/20/2022]
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17
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Hillelsohn JH, Duty BD, Okhunov Z, Kavoussi LR. Laparoscopic retroperitoneal lymph node dissection for testicular cancer. Arab J Urol 2012; 10:66-73. [PMID: 26558006 PMCID: PMC4442896 DOI: 10.1016/j.aju.2012.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Revised: 01/04/2012] [Accepted: 01/04/2012] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Laparoscopic retroperitoneal lymph node dissection (L-RPLND) was introduced over 20 years ago as a less invasive alternative to open node dissection. In this review we summarise the indications, surgical technique and outcomes of L-RPLND in the treatment of testicular cancer. METHODS We searched MEDLINE using the terms 'laparoscopy', 'laparoscopic', 'retroperitoneal lymph node dissection', 'RPLND' and 'testicular neoplasms'. Articles were selected on the basis of their relevance, study design and content, with an emphasis on more recent data. RESULTS We found 14 pertinent studies, which included >1300 patients who received either L-RPLND (515) or open RPLND (788). L-RPLND was associated with longer mean operative times (204 vs. 186 min), but shorter hospital stays (3.3 vs. 6.6 days) and lower complication rates (15.6% vs. 33%). Oncological outcomes were similar between L-RPLND and open RPLND, with local relapse rates of 1.3% and 1.4%, incidence of distal progression of 3.3% and 6.1%, biochemical failure in 0.9% and 1.1% and cure rates of 100% and 99.6%, respectively. CONCLUSION There are no randomised controlled studies comparing L-RPLND with open RPLND. A review of case and comparative series showed similar perioperative and oncological outcomes. Patients undergoing L-RPLND on average have shorter hospital stays, a quicker return to normal activity and improved cosmesis.
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Affiliation(s)
| | - Brian D Duty
- The Arthur Smith Institute for Urology, Lake Success, NY, USA
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18
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Schwartz MJ, Kavoussi LR. Controversial technology: the Chunnel and the laparoscopic retroperitoneal lymph node dissection (RPLND). BJU Int 2010; 106:950-9. [PMID: 20840317 DOI: 10.1111/j.1464-410x.2010.09659.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
• Laparoscopic retroperitoneal lymph node dissection (L-RPLND) was first introduced in 1992, initially as a staging procedure. • With advances in instrumentation and laparoscopic techniques, as well as improved understanding of laparoscopic anatomy, L-RPLND has developed to duplicate open RPLND. • Unlike the relatively rapid adoption of laparoscopy for other applications including nephrectomy and prostatectomy, L-RPLND has been slow to be universally accepted. • The limited numbers of patients requiring RPLND and technical challenges in performing the dissection have undoubtedly contributed to its delayed reception. • This review will present available data on this technique and discuss issues potentially inhibiting acceptance by traditional surgeons.
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Affiliation(s)
- Michael J Schwartz
- Arthur Smith Institute for Urology, North Shore/Long Island Jewish Health System, New Hyde Park, NY, USA
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19
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Kim BS, Yoo ES, Kim TH, Kwon TG. Chylous ascites as a complication of laparoscopic nephrectomy. J Urol 2010; 184:570-4. [PMID: 20639020 DOI: 10.1016/j.juro.2010.03.128] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2009] [Indexed: 01/02/2023]
Abstract
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.
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Affiliation(s)
- Bum Soo Kim
- Department of Urology, School of Medicine, Kyungpook National University, Daegu, Korea
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Prolonged lymphatic leak after retroperitoneal lymph node dissection: a case report. J Med Case Rep 2009; 3:8704. [PMID: 19830237 PMCID: PMC2737793 DOI: 10.4076/1752-1947-3-8704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2008] [Accepted: 03/24/2009] [Indexed: 01/31/2023] Open
Abstract
Introduction Persistent lymphatic drainage following retroperitoneal lymph node dissection for testicular tumor is an uncommon complication. Case presentation We describe a 21-year old man of Caucasian origin who had metastatic non-seminomatous germ cell tumor of the testis, and underwent retroperitoneal lymph node dissection, nephrectomy and partial inferior vena cava excision for a residual mass. The patient subsequently developed persistent lymphatic drainage causing foot drop that eventually responded to conservative medical and surgical measures. Conclusion This postoperative condition usually responds well to conservative measures but has the potential for serious morbidity if it is not managed appropriately.
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Rodríguez Alonso A, González Blanco A, Barbagelata López A, Bonelli Martín C, Fernández López M, Cuerpo Pérez MA. [Chylous ascites following radical nephrectomy and retroperitoneal lymphadenectomy]. Actas Urol Esp 2009; 33:192-6. [PMID: 19418845 DOI: 10.1016/s0210-4806(09)74122-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Chylous ascites consists of the accumulation of chyle in the abdominal cavity. Postoperative presentation develops as a consequence of unrecognized injury of cisterna chyli or one of its major lumbar tributaries. It usually present as abdominal distention and pain or drainage of milky fluid from surgical wound or abdominal drain. Diagnosis is established by cytochemical analysis of fluid and staining with Sudan III, that shows fat globules, leukocytes with lymphocytic predominance and a high triglyceride content. We present a case of postoperative chylous ascites following radical nephrectomy and retroperitoneal lymphadenectomy for renal cancer, which successfully respond to conservative measures: total parenteral nutrition and octreotide.
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Affiliation(s)
- Andrés Rodríguez Alonso
- Servicio de Urología, Hospital Arquitecto Marcide-Profesor Novoa Santos, Ferrol, La Coruña, España.
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Kim BS, Yoo ES, Kwon TG. Complications of transperitoneal laparoscopic nephrectomy: a single-center experience. Urology 2009; 73:1283-7. [PMID: 19362334 DOI: 10.1016/j.urology.2009.01.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2008] [Revised: 11/24/2008] [Accepted: 01/12/2009] [Indexed: 01/02/2023]
Abstract
OBJECTIVES To present the incidence of complications of transperitoneal laparoscopic nephrectomy performed for various indications during a 6-year period. METHODS From 2002 to 2007, 505 transperitoneal laparoscopic nephrectomies were performed, consisting of 125 live donor, 212 radical, 80 simple, and 28 partial nephrectomies and 60 nephroureterectomies. We retrospectively analyzed the factors related to perioperative complications, including the type of operation, body mass index, history of abdominal surgery, and American Society of Anesthesiologists score. RESULTS The overall complication rate was 13.7% (69/505). Major complications requiring open conversion or reoperation occurred in 15 patients (3.0%). The remaining 54 patients experienced minor surgical or postoperative medical problems. The mortality rate in our series was 0%. The complication rates by the type of operation were not significantly different. Patients with a history of abdominal surgery demonstrated slightly greater complication rates (19.2% vs 12.6%, P = .069). When stratified by a body mass index of <25 kg/m(2) and <25 kg/m(2), no statistically significant difference was found in the complication rates (13.1% vs 15.6%, respectively, P = .067). Patients with greater American Society of Anesthesiologists scores had greater complication rates (P = .038). The intraoperative complication rates decreased as our experience with laparoscopic surgery increased (P = .042); however, the total complication rates remained constant throughout the study period. CONCLUSIONS In consideration of the contributing factors, the complication rates of transperitoneal laparoscopic nephrectomy were not related to the type of operation, body mass index, or history of abdominal operation but to the American Society for Anesthesiologists score. Complications unique to laparoscopic nephrectomy exist but they decrease with experience.
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Affiliation(s)
- Bum Soo Kim
- Department of Urology, Kyungpook National University Hospital, Daegu, Korea
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Breda A, Finelli A, Janetschek G, Porpiglia F, Montorsi F. Complications of laparoscopic surgery for renal masses: prevention, management, and comparison with the open experience. Eur Urol 2009; 55:836-50. [PMID: 19168276 DOI: 10.1016/j.eururo.2009.01.018] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Accepted: 01/09/2009] [Indexed: 01/06/2023]
Abstract
CONTEXT The initial excitement about the laparoscopic treatment of renal masses has been tempered by concerns related to increased operative time, technical complexity, and the suitability of laparoscopic approaches to oncologic surgery. OBJECTIVE To provide a comprehensive review of intraoperative and postoperative complications and their prevention and management during laparoscopic surgery of renal tumors. EVIDENCE ACQUISITION A literature review of the Medline and Google Scholar databases was performed, searching for renal cell carcinoma, renal mass, laparoscopy, laparoscopic radical nephrectomy, open radical nephrectomy, laparoscopic partial nephrectomy, open partial nephrectomy, laparoscopic cryoablation, laparoscopic radiofrequency ablation, complications, intra-operative, and post-operative. English-language articles published between 1990 and 2008 were reviewed. EVIDENCE SYNTHESIS Laparoscopic radical nephrectomy (LRN), whether transperitoneal or retroperitoneal, can be performed safely. The overall complication rate is low and does not significantly differ from that of the open experience. Laparoscopic partial nephrectomy (LPN), in contrast, is a technically challenging procedure. Although the intermediate oncologic outcomes are comparable to those of the open experience, there are concerns related to warm ischemia time, and there is a risk of major complications such as urinary leakage and hemorrhage requiring transfusion. Laparoscopic-assisted ablative therapies (cryotherapy and radiofrequency) are being performed more commonly for the treatment of small exophytic renal lesions with a low complication rate and intermediate oncologic outcomes similar to LRN and LPN. CONCLUSIONS Complications associated with the laparoscopic management of renal masses vary among the different procedures and with surgeon experience. The rate of complication appears to be similar to that of open surgery.
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Affiliation(s)
- Alberto Breda
- Department of Urology, University of California, Los Angeles, CA 90095, United States.
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Kenney PA, Tuerk IA. Complications of laparoscopic retroperitoneal lymph node dissection in testicular cancer. World J Urol 2008; 26:561-9. [PMID: 18594824 DOI: 10.1007/s00345-008-0299-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2008] [Accepted: 06/09/2008] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES A proposed benefit of laparoscopic retroperitoneal lymph node dissection (LRPLND) is more favorable morbidity in comparison to open retroperitoneal lymph node dissection (RPLND). The objective of this review is to examine and summarize the literature regarding complications in both primary and post-chemotherapy LRPLND (PC-LRPLND) and, where appropriate, we include the opinions of the senior author regarding management. METHODS A MEDLINE search was performed using the terms "laparoscopy" or "laparoscopic," "retroperitoneal lymph node dissection" or "RPLND," and "testicular neoplasms." Articles were included on the basis of study design and content. For series updated over time, an effort was made to include only the most recent data to avoid duplicate reporting of patients. RESULTS In primary LRPLND, vascular injury is the most common complication, occurring in 2.2-20% of reported cases. Bowel injury is rarely reported but potentially catastrophic. Rates of retrograde ejaculation are less than 5%. Chylous ascites and lymphocele are delayed post-operative complications. Rarely reported complications include nerve injury, retroperitoneal hematoma, and ureteral injury requiring internal stent placement. PC-LRPLND is challenging, with high rates of conversion and complications. Hemorrhage is common. Retrograde ejaculation is several-fold more common in PC-LRPLND than in primary LRPLND. No peri-operative mortality has been reported for either LRPLND or PC-LRPLND. CONCLUSIONS LRPLND and PC-LRPLND are technically demanding. Hemorrhage and vascular injury are the most commonly reported complications. Prospective studies will help clarify the proposed benefits of LRPLND.
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Affiliation(s)
- Patrick A Kenney
- Institute of Urology, Lahey Clinic Medical Center, Burlington, MA 01805, USA
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Nishizawa K, Ito N, Yamamoto S, Kamoto T, Ogawa O. Successful laparoscopic management of chylous ascites following laparoscopic radical nephrectomy. Int J Urol 2006; 13:619-21. [PMID: 16771738 DOI: 10.1111/j.1442-2042.2006.01372.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
A 44-year-old woman developed chylous ascites following laparoscopic transperitoneal left radical nephrectomy with para-aortic lymph node dissection. Because conservative managements failed to stop the lymphatic leakage, laparoscopic lymphostasis was performed. Drinking milk 6 h prior to the operation enabled visualization of chylous ascites. Although a definite fistula was hard to identify, most of the chylous leak disappeared after ligation of the para-aortic tissues at the distal and proximal ends of the previous lymph node dissection. Laparoscopic ligation of the para-aortic bundle of lymph ducts was effective in managing long-standing postoperative chylous ascites.
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Affiliation(s)
- Koji Nishizawa
- Kyoto University Hospital, Department of Urology, Kyoto, Japan.
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Negoro H, Oka H, Kawakita M. Two cases of chyloretroperitoneum following retroperitoneoscopic nephroureterectomy. Int J Urol 2006; 13:487-9. [PMID: 16734885 DOI: 10.1111/j.1442-2042.2006.01427.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Post-operative chyloretroperitoneum is a rare complication in urological surgery. We experienced two cases of post-operative chyloretroperitoneum following retroperitoneoscopic left nephroureterectomy. Both cases were treated successfully with drainage, low fat diet, total parenteral nutrition (case 1 only), sclerotherapy and somatostatin analog. Laparoscopic procedures are supposed to have a higher risk of chylous complications, as CO2 pressure appears to make the operator overlook suppressing the lymphatic leakage from the resected lymphatic channels.
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Caumartin Y, Pouliot F, Sabbagh R, Dujardin T. Chylous ascites as a complication of laparoscopic donor nephrectomy. Transpl Int 2006; 18:1378-81. [PMID: 16297058 DOI: 10.1111/j.1432-2277.2005.00219.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Laparoscopic living donor nephrectomy (LLDN) is a minimally invasive technique for kidney procurement and was developed with the hope of reducing the disincentives associated with live renal donation. Compared with open donor nephrectomy (ODN), this alternative has many advantages including less postoperative pain and earlier return to work. Unfortunately, these benefits are sometimes negated by postoperative complications. Among these, chylous ascites (CA) is a rare but serious problem that is usually managed conservatively. We report the case of a living donor who developed CA refractory to initial conservative management and surgical treatment. We also discuss the role of surgery in the treatment of CA following LLDN.
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Affiliation(s)
- Yves Caumartin
- Service d'Urologie, Centre Hospitalier Universitaire de Québec, pavillon Hôtel-Dieu de Québec, Université Laval, Québec, Canada
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Link RE, Amin N, Kavoussi LR. Chylous ascites following retroperitoneal lymphadenectomy for testes cancer. ACTA ACUST UNITED AC 2006; 3:226-32; quiz 233. [PMID: 16607371 DOI: 10.1038/ncpuro0457] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2005] [Accepted: 02/21/2006] [Indexed: 11/08/2022]
Abstract
BACKGROUND A 31-year-old man underwent a radical orchiectomy for a stage I mixed germ-cell tumor with angiolymphatic invasion. A subsequent laparoscopic retroperitoneal lymphadenectomy was complicated by a laceration to the aorta at the ostia of the more inferior of two right renal arteries. This was repaired following conversion to an open laparotomy. The patient presented 14 days later with genital swelling and increasing abdominal girth. INVESTIGATIONS Physical examination, abdominal and pelvic CT, laboratory albumin testing, lymphoscintogram and lymphangiogram. DIAGNOSIS Chylous ascites with tracking of lymphatic fluid into the left groin through a defect in the internal inguinal ring. MANAGEMENT Conservative management with salt restriction, a medium-chain fatty-acid diet and diuretics; exploratory laparoscopy, during which a small left inguinal hernia was repaired and chylous fluid was drained. Following further leakage, the patient was placed on total parenteral nutrition, followed by image-guided sclerotherapy with doxycycline.
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Affiliation(s)
- Richard E Link
- Division of Endourology and Minimally-Invasive Surgery, Scott Department of Urology at Baylor College of Medicine, Houston, TX 77030, USA.
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Huang Q, Jiang ZW, Jiang J, Li N, Li JS. Chylous ascites: Treated with total parenteral nutrition and somatostatin. World J Gastroenterol 2004; 10:2588-91. [PMID: 15300913 PMCID: PMC4572170 DOI: 10.3748/wjg.v10.i17.2588] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIM: To determine the effects of total parenteral nutrition and somatostatin on patients with chylous ascites.
METHODS: Five patients were diagnosed with chylous ascites on the basis of laboratory findings of ascites sample from Nov 1999 to May 2003. Total parenteral nutrition and somatostatin or its analogue was administered to 4 patients, while the other one only received total parenteral nutrition. All the patients had persistent peritoneal drainage, with the quantity and quality of drainage fluid observed daily. Necessary supportive treatments were given to the patients individually during the therapy.
RESULTS: Two of 4 patients who received somatostatin therapy obtained complete recovery within 10 d without any recurrence while on a normal diet. In these 2 patients, the peritoneal drainage reduced to zero in one and the other's decreased from 2000 mL to 80 mL with a clear appearance and negative qualitative analysis of chyle. Recurrent chylous ascites, though relieved effectively by the same method every time, developed in one patient with advanced pancreatic cancer. The other patient's lymphatic fistula was blocked with the fibrin glue after conservative treatment. The patient who only received total parenteral nutrition was cured 24 d after therapy.
CONCLUSION: Total parenteral nutrition along with somatostatin can relieve the symptoms and close the fistula in patients with chylous ascites rapidly. It appears to be an effective therapy available for the treatment of chylous ascites caused by various disorders.
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Affiliation(s)
- Qi Huang
- Institute of General Surgery, Jinling Hospital, 305 Zhongshan East Road, Nanjing 210002, Jiangsu Province, China
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