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Du L, Wei N, Maiwall R, Song Y. Differential diagnosis of ascites: etiologies, ascitic fluid analysis, diagnostic algorithm. Clin Chem Lab Med 2024; 62:1266-1276. [PMID: 38112289 DOI: 10.1515/cclm-2023-1112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/07/2023] [Indexed: 12/21/2023]
Abstract
Ascites is the pathological accumulation of fluid within the peritoneal cavity. It often occurs as results of liver cirrhosis, malignant neoplasia, tuberculous infection, cardiac insufficiency, renal diseases, etc. Determining the etiology is an essential step in the management of patients with new-onset ascites. Abdominal paracentesis with appropriate ascitic fluid analysis is probably the most cost-effective method of determining the cause of ascites. We performed a literature search of PubMed and identified articles published in the field of ascites, to evaluate diagnostic values of various parameters in defining the etiologies of ascites and then provides diagnostic algorithm for patients with new-onset ascites. In patients with ascites, the constituent ratio of underlying etiology varies between developed and developing countries. It is a challenge to define the etiologies of ascites in developing countries. Routine ascitic fluid analysis should include the serum ascites albumin gradient (SAAG), total protein concentration, cell count and differential. Optional ascitic fluid analysis includes cholesterol, fluid culture, cytology, tumor markers, lactate dehydrogenase, adenosine deaminase (ADA), triglyceride, amylase, glucose, brain natriuretic peptide (BNP), etc. Our review evaluated diagnostic values of the above parameters in defining the etiologies of ascites. Diagnostic algorithm established in this review would provide a practical and convenient diagnostic strategy for clinicians in diagnosing patients with new-onset ascites.
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Affiliation(s)
- Li Du
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P.R. China
| | - Ning Wei
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P.R. China
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Yuhu Song
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P.R. China
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Sinicropi T, Mazzeo C, Sofia C, Biondo SA, Cucinotta E, Fleres F. Acute Chyloperitoneum with Small Bowel Volvulus: Case Series and Systematic Review of the Literature. J Clin Med 2024; 13:2816. [PMID: 38792360 PMCID: PMC11122546 DOI: 10.3390/jcm13102816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/02/2024] [Accepted: 05/01/2024] [Indexed: 05/26/2024] Open
Abstract
Introduction: Chyloperitoneum arises from lymph leakage into the abdominal cavity, leading to an accumulation of milky fluid rich in triglycerides. Diagnosis can be challenging, and mortality rates vary depending on the underlying cause, with intestinal volvulus being just one potential acute cause. Despite its rarity, our case series highlights chyloperitoneum associated with non-ischemic small bowel volvulus. The aims of our study include assessing the incidence of this association and evaluating diagnostic and therapeutic approaches. Material and Methods: We present two cases of acute abdominal peritonitis with suspected small bowel volvulus identified via contrast-enhanced computed tomography (CT). Emergency laparotomy revealed milky-free fluid and bowel volvulus. Additionally, we conducted a systematic review up to 31 October 2023, identifying 15 previously reported cases of small bowel volvulus and chyloperitoneum in adults (via the PRISMA scheme). Conclusions: Clarifying the etiopathogenetic mechanism of chyloperitoneum requires specific diagnostic tools. Magnetic resonance imaging (MRI) may be useful in non-emergency situations, while contrast-enhanced CT is employed in emergencies. Although small bowel volvulus infrequently causes chyloperitoneum, prompt treatment is necessary. The volvulus determines lymphatic flow obstruction at the base of the mesentery, with exudation and chyle accumulation in the abdominal cavity. Derotation of the volvulus alone may resolve chyloperitoneum without intestinal ischemia.
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Affiliation(s)
- Teresa Sinicropi
- Section of General Surgery, Department of Human Pathology of the Adult and Evolutive Age “Gaetano Barresi”, University of Messina, Via Consolare Valeria, 98125 Messina, Italy; (T.S.); (C.M.); (S.A.B.); (E.C.)
| | - Carmelo Mazzeo
- Section of General Surgery, Department of Human Pathology of the Adult and Evolutive Age “Gaetano Barresi”, University of Messina, Via Consolare Valeria, 98125 Messina, Italy; (T.S.); (C.M.); (S.A.B.); (E.C.)
| | - Carmelo Sofia
- Section of Radiological Sciences, Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Policlinico “G. Martino” Via Consolare Valeria 1, 98125 Messina, Italy;
| | - Santino Antonio Biondo
- Section of General Surgery, Department of Human Pathology of the Adult and Evolutive Age “Gaetano Barresi”, University of Messina, Via Consolare Valeria, 98125 Messina, Italy; (T.S.); (C.M.); (S.A.B.); (E.C.)
| | - Eugenio Cucinotta
- Section of General Surgery, Department of Human Pathology of the Adult and Evolutive Age “Gaetano Barresi”, University of Messina, Via Consolare Valeria, 98125 Messina, Italy; (T.S.); (C.M.); (S.A.B.); (E.C.)
| | - Francesco Fleres
- Section of General Surgery, Department of Human Pathology of the Adult and Evolutive Age “Gaetano Barresi”, University of Messina, Via Consolare Valeria, 98125 Messina, Italy; (T.S.); (C.M.); (S.A.B.); (E.C.)
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Gondolesi GE, Rumbo C, Montes L, Novellis L, Ramisch D, Henríquez AR, Ortega M, Viano F, Schiano T, Descalzi V, Tiribelli C, Oltean M, Barros-Schelotto P, Solar H. Pathophysiology of ascites: The importance of the intestine. A surgical contribution to the understanding of a medical problem. Ann Hepatol 2024; 29:101498. [PMID: 38479458 DOI: 10.1016/j.aohep.2024.101498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 03/03/2024] [Indexed: 03/21/2024]
Abstract
The understanding of the mechanisms for the development of ascites has evolved over the years, involving the liver, peritoneum, heart, and kidneys as key responsible for its formation. In this article, we review the pathophysiology of ascites formation, introducing the role of the intestine as a major responsible for ascites production through "a game changer" case.
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Affiliation(s)
- Gabriel E Gondolesi
- General Surgery, Liver-pancreas and Intestinal transplantation. Hospital Universitario Fundación Favaloro. IMeTTyB, Universidad Favaloro-CONICET, Buenos Aires, Argentina.
| | - Carolina Rumbo
- General Surgery, Liver-pancreas and Intestinal transplantation. Hospital Universitario Fundación Favaloro. IMeTTyB, Universidad Favaloro-CONICET, Buenos Aires, Argentina
| | - Leonardo Montes
- General Surgery, Liver-pancreas and Intestinal transplantation. Hospital Universitario Fundación Favaloro. IMeTTyB, Universidad Favaloro-CONICET, Buenos Aires, Argentina
| | - Lucia Novellis
- General Surgery, Liver-pancreas and Intestinal transplantation. Hospital Universitario Fundación Favaloro. IMeTTyB, Universidad Favaloro-CONICET, Buenos Aires, Argentina
| | - Diego Ramisch
- General Surgery, Liver-pancreas and Intestinal transplantation. Hospital Universitario Fundación Favaloro. IMeTTyB, Universidad Favaloro-CONICET, Buenos Aires, Argentina
| | - Ariel Riquelme Henríquez
- General Surgery, Liver-pancreas and Intestinal transplantation. Hospital Universitario Fundación Favaloro. IMeTTyB, Universidad Favaloro-CONICET, Buenos Aires, Argentina
| | - Mariana Ortega
- General Surgery, Liver-pancreas and Intestinal transplantation. Hospital Universitario Fundación Favaloro. IMeTTyB, Universidad Favaloro-CONICET, Buenos Aires, Argentina
| | - Federico Viano
- Internal Medicine. Metabolic and Nutritional Support Unit. Sanatorio Allende, Córdoba, Argentina
| | - Thomas Schiano
- Recanati Miller Transplantation Institute Mount Sinai School of Medicine, New York, United States of America
| | - Valeria Descalzi
- General Surgery, Liver-pancreas and Intestinal transplantation. Hospital Universitario Fundación Favaloro. IMeTTyB, Universidad Favaloro-CONICET, Buenos Aires, Argentina
| | | | - Mihai Oltean
- The Transplant Institute. Sahlgrenska University Hospital, Gothenburg 413 45, Sweden
| | - Pablo Barros-Schelotto
- General Surgery, Liver-pancreas and Intestinal transplantation. Hospital Universitario Fundación Favaloro. IMeTTyB, Universidad Favaloro-CONICET, Buenos Aires, Argentina
| | - Héctor Solar
- General Surgery, Liver-pancreas and Intestinal transplantation. Hospital Universitario Fundación Favaloro. IMeTTyB, Universidad Favaloro-CONICET, Buenos Aires, Argentina
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Abokhozima A, Zidan MH, Abo Elmagd A, Alokl M, Altabbaa H, Al Sayed M, Selim A. Lymphatic Chyle Duct Injury and Identification During Laparoscopic Sleeve Gastrectomy Preventing Postoperative Chylous Ascites. Obes Surg 2024; 34:1995-2000. [PMID: 38589758 PMCID: PMC11031454 DOI: 10.1007/s11695-024-07215-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 04/10/2024]
Abstract
We present a case of intraoperative detection of an iatrogenic chyle duct injury during laparoscopic sleeve gastrectomy. The chyle duct injury was identified and managed by ligature, preventing postoperative chylous ascites.
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Affiliation(s)
- Ahmed Abokhozima
- Alexandria University, El-Shatby, 22 El-Guish Road, Alexandria, 21526, Alexandria, Egypt
- Ekbal Hospital, 10 Hassan Amin Street, Alexandria, Egypt
| | - Mohamed H Zidan
- Alexandria University, El-Shatby, 22 El-Guish Road, Alexandria, 21526, Alexandria, Egypt.
- Alexandria Main University Hospital, Al Mothaf, Al Mesallah Sharq, Al Attarin, Alexandria, 5372066, Egypt.
- Ekbal Hospital, 10 Hassan Amin Street, Alexandria, Egypt.
| | - Ahmed Abo Elmagd
- Alexandria University, El-Shatby, 22 El-Guish Road, Alexandria, 21526, Alexandria, Egypt
- Alexandria Main University Hospital, Al Mothaf, Al Mesallah Sharq, Al Attarin, Alexandria, 5372066, Egypt
- Ekbal Hospital, 10 Hassan Amin Street, Alexandria, Egypt
| | - Mohammed Alokl
- Alexandria University, El-Shatby, 22 El-Guish Road, Alexandria, 21526, Alexandria, Egypt
- Ekbal Hospital, 10 Hassan Amin Street, Alexandria, Egypt
| | - Hashem Altabbaa
- Alexandria University, El-Shatby, 22 El-Guish Road, Alexandria, 21526, Alexandria, Egypt
| | - Mohamed Al Sayed
- Alexandria University, El-Shatby, 22 El-Guish Road, Alexandria, 21526, Alexandria, Egypt
- Alexandria Main University Hospital, Al Mothaf, Al Mesallah Sharq, Al Attarin, Alexandria, 5372066, Egypt
| | - Aliaa Selim
- Alexandria University, El-Shatby, 22 El-Guish Road, Alexandria, 21526, Alexandria, Egypt
- Ekbal Hospital, 10 Hassan Amin Street, Alexandria, Egypt
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5
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DiBattista JV, Odenwald MA, Te H. Successful Treatment of Refractory Chylous Ascites With Octreotide in a Patient With Decompensated Cirrhosis. ACG Case Rep J 2024; 11:e01322. [PMID: 38560017 PMCID: PMC10977527 DOI: 10.14309/crj.0000000000001322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/28/2024] [Indexed: 04/04/2024] Open
Abstract
Chylous ascites is a rare manifestation of decompensated cirrhosis that is associated with increased short-term mortality. Exclusion of other etiologies must be performed to allow for appropriate management, which itself can be a challenge in the setting of decompensated cirrhosis. We report a case of chylous ascites in a patient with decompensated cirrhosis that was successfully managed with octreotide before liver transplantation.
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Affiliation(s)
- Jacob V. DiBattista
- Section of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - Matthew A. Odenwald
- Section of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - Helen Te
- Section of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Chicago Medicine, Chicago, IL
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6
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Zenati H, Jallali M, Korbi A, Chaka A, Jabra SB, Korbi I, Noomen F. Acute primary chylous peritonitis mimicking acute abdomen: a case report and literature review. Pan Afr Med J 2024; 47:131. [PMID: 38881770 PMCID: PMC11178667 DOI: 10.11604/pamj.2024.47.131.42794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 03/05/2024] [Indexed: 06/18/2024] Open
Abstract
Acute chylous peritonitis is an uncommon medical condition that can occur suddenly, resulting in the buildup of chylous fluid in the peritoneal cavity. It is considered idiopathic because the exact cause is often unknown. The symptoms of acute chylous idiopathic peritonitis can mimic other abdominal emergencies, making it challenging to diagnose and manage, requiring a multidisciplinary approach. We present a case report of acute idiopathic chylous peritonitis miming acute abdomen, how was successfully treated with surgery, and provide a comprehensive review of the available literature on this topic. Chylous peritonitis is a rare condition whose clinical presentation mimics an acute abdomen. It is necessary to undertake careful exploration. An emergent laparotomy is indicated to treat the peritonitis and search for and treat the underlying cause.
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Affiliation(s)
- Hanen Zenati
- Department of Visceral and Digestive Surgery, University Hospital of Monastir, Monastir, Tunisia
| | - Maissa Jallali
- Department of Visceral and Digestive Surgery, University Hospital of Monastir, Monastir, Tunisia
| | - Asma Korbi
- Department of Gynecology, University Hospital of Monastir, Monastir, Tunisia
| | - Amina Chaka
- Department of Visceral and Digestive Surgery, University Hospital of Monastir, Monastir, Tunisia
| | - Sadok Ben Jabra
- Department of Visceral and Digestive Surgery, University Hospital of Monastir, Monastir, Tunisia
| | - Ibtissem Korbi
- Department of Visceral and Digestive Surgery, University Hospital of Monastir, Monastir, Tunisia
| | - Faouzi Noomen
- Department of Visceral and Digestive Surgery, University Hospital of Monastir, Monastir, Tunisia
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Imai H, Saijo K, Takenaga N, Komine K, Ouchi K, Kasahara Y, Ishikawa S, Sasaki K, Yoshida Y, Shirota H, Takahashi M, Ishioka C. Chylous Ascites Associated with Advanced Pancreatic Cancer That Improved with Appropriate Treatment: A Case Report. Curr Oncol 2024; 31:1477-1482. [PMID: 38534945 PMCID: PMC10969774 DOI: 10.3390/curroncol31030112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 03/09/2024] [Accepted: 03/11/2024] [Indexed: 05/26/2024] Open
Abstract
Chylous ascites is a rare form of ascites with high triglyceride content arising from the thoracoabdominal lymph nodes in the peritoneal cavity due to various benign or malignant etiologies, including pancreatic cancer. During cancer chemotherapy, the accumulation of ascites can lead to the deterioration of the patient's general condition, making chemotherapy administration difficult, and resulting in a poor prognosis. We encountered a rare case of chylous ascites complicated by advanced pancreatic cancer. The patient presented with a discrepancy between the shrinkage of the pancreatic cancer and the accumulation of ascites. Therefore, we were able to promptly diagnose chylous ascites by performing biochemical tests. The patient was treated with octreotide, reportedly effective in treating chylous ascites, which rapidly improved the chylous ascites and general condition of the patient, allowing the patient to continue chemotherapy for pancreatic cancer. Therefore, physicians should consider the possibility of chylous ascites when clinically unexplained ascites are observed in patients with advanced cancer. The investigation and treatment of chylous ascites should be initiated as soon as possible.
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Affiliation(s)
- Hiroo Imai
- Department of Medical Oncology, Tohoku University Hospital, Sendai 980-8547, Japan; (H.I.); (K.S.); (K.K.); (K.O.); (Y.K.); (S.I.); (K.S.); (Y.Y.); (H.S.); (M.T.)
- Department of Clinical Oncology, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan;
| | - Ken Saijo
- Department of Medical Oncology, Tohoku University Hospital, Sendai 980-8547, Japan; (H.I.); (K.S.); (K.K.); (K.O.); (Y.K.); (S.I.); (K.S.); (Y.Y.); (H.S.); (M.T.)
- Department of Clinical Oncology, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan;
| | - Noriko Takenaga
- Department of Clinical Oncology, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan;
| | - Keigo Komine
- Department of Medical Oncology, Tohoku University Hospital, Sendai 980-8547, Japan; (H.I.); (K.S.); (K.K.); (K.O.); (Y.K.); (S.I.); (K.S.); (Y.Y.); (H.S.); (M.T.)
- Department of Clinical Oncology, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan;
| | - Kota Ouchi
- Department of Medical Oncology, Tohoku University Hospital, Sendai 980-8547, Japan; (H.I.); (K.S.); (K.K.); (K.O.); (Y.K.); (S.I.); (K.S.); (Y.Y.); (H.S.); (M.T.)
- Department of Clinical Oncology, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan;
| | - Yuki Kasahara
- Department of Medical Oncology, Tohoku University Hospital, Sendai 980-8547, Japan; (H.I.); (K.S.); (K.K.); (K.O.); (Y.K.); (S.I.); (K.S.); (Y.Y.); (H.S.); (M.T.)
- Department of Clinical Oncology, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan;
| | - Shiori Ishikawa
- Department of Medical Oncology, Tohoku University Hospital, Sendai 980-8547, Japan; (H.I.); (K.S.); (K.K.); (K.O.); (Y.K.); (S.I.); (K.S.); (Y.Y.); (H.S.); (M.T.)
- Department of Clinical Oncology, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan;
| | - Keiju Sasaki
- Department of Medical Oncology, Tohoku University Hospital, Sendai 980-8547, Japan; (H.I.); (K.S.); (K.K.); (K.O.); (Y.K.); (S.I.); (K.S.); (Y.Y.); (H.S.); (M.T.)
- Department of Clinical Oncology, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan;
| | - Yuya Yoshida
- Department of Medical Oncology, Tohoku University Hospital, Sendai 980-8547, Japan; (H.I.); (K.S.); (K.K.); (K.O.); (Y.K.); (S.I.); (K.S.); (Y.Y.); (H.S.); (M.T.)
- Department of Clinical Oncology, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan;
| | - Hidekazu Shirota
- Department of Medical Oncology, Tohoku University Hospital, Sendai 980-8547, Japan; (H.I.); (K.S.); (K.K.); (K.O.); (Y.K.); (S.I.); (K.S.); (Y.Y.); (H.S.); (M.T.)
- Department of Clinical Oncology, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan;
| | - Masanobu Takahashi
- Department of Medical Oncology, Tohoku University Hospital, Sendai 980-8547, Japan; (H.I.); (K.S.); (K.K.); (K.O.); (Y.K.); (S.I.); (K.S.); (Y.Y.); (H.S.); (M.T.)
- Department of Clinical Oncology, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan;
| | - Chikashi Ishioka
- Department of Medical Oncology, Tohoku University Hospital, Sendai 980-8547, Japan; (H.I.); (K.S.); (K.K.); (K.O.); (Y.K.); (S.I.); (K.S.); (Y.Y.); (H.S.); (M.T.)
- Department of Clinical Oncology, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan;
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Zou H, Van Beynen J, Ritzema J. Management of Idiopathic Infantile Chylous Ascites. Cureus 2024; 16:e55965. [PMID: 38601390 PMCID: PMC11006280 DOI: 10.7759/cureus.55965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2024] [Indexed: 04/12/2024] Open
Abstract
Chylous ascites is the accumulation of triglyceride-rich lymphatic fluid in the peritoneal cavity. We present the case of a four-month-old male admitted for abdominal distension. A large volume of ascites was confirmed by imaging. Paracentesis indicated chylous aspirate and drainage was performed using a pigtail catheter. Total parenteral nutrition was initiated and fluconazole prophylaxis was implemented for seven days. Twenty-six days after admission, abdominopelvic magnetic resonance imaging showed trace ascites but no signs of lymphatic malformation. He began transitioning to nasogastric feeds with plans to eventually resume oral feeds. This case not only highlights the limitations in our abilities to definitively identify the etiology of pediatric chylous ascites but also demonstrates how chylous ascites management can carefully combine conservative and surgical strategies to optimize patient outcomes.
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Affiliation(s)
- Henry Zou
- Pediatrics, Michigan State University College of Human Medicine, Grand Rapids, USA
| | | | - Joshua Ritzema
- Pediatrics, Michigan State University College of Human Medicine, Grand Rapids, USA
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Na JE, Kim JE, Park S, Kim ER, Hong SN, Kim YH, Chang DK. Experience of primary intestinal lymphangiectasia in adults: Twelve case series from a tertiary referral hospital. World J Clin Cases 2024; 12:746-757. [PMID: 38322684 PMCID: PMC10841145 DOI: 10.12998/wjcc.v12.i4.746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/17/2023] [Accepted: 01/08/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND While primary intestinal lymphangiectasia (PIL) is considered a rare condition, there have been several reported cases in adults. Nevertheless, the absence of clear guidance from diagnosis to treatment and prognosis poses challenges for both physicians and patients. AIM To enhance understanding by investigating clinical presentation, diagnosis, treatment, complications, and prognoses in adult PIL cases. METHODS We enrolled adult patients diagnosed with PIL between March 2016 and September 2021. The primary outcome involved examining the diagnosis and treatment process of these patients. The secondary outcomes included identifying complications (infections, thromboembolism) and assessing prognoses (frequency of hospitalization and mortality) during the follow-up period. RESULTS Among the 12 included patients, peripheral edema (100%) and diarrhea (75%) were the main presenting complaints. Laboratory tests showed that all the patients exhibited symptoms of hypoalbuminemia and hypogammaglobulinemia. Radiologically, the predominant findings were edema of the small intestine (67%) and ascites (58%). The typical endoscopic finding with a snowflake appearance was observed in 75% of patients. Among the 12 patients, two responded positively to octreotide and sirolimus, and eight who could undergo maintenance therapy discontinued subsequently. Complications due to PIL led to infection in half of the patients, thromboembolism in three patients, and one death. CONCLUSION PIL can be diagnosed in adults across various age groups, with different severity and treatment responses among patients, leading to diverse complications and prognoses. Consequently, tailored treatments will be necessary. We anticipate that our findings will contribute to the management of PIL, an etiology of protein-losing enteropathy.
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Affiliation(s)
- Ji Eun Na
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Busan 48108, South Korea
| | - Ji Eun Kim
- Department of Medicine, Samsung Medical Center, Seoul 06351, South Korea
| | - Sujin Park
- Department of Pathology, Samsung Medical Center, Seoul 06351, South Korea
| | - Eun Ran Kim
- Department of Medicine, Samsung Medical Center, Seoul 06351, South Korea
| | - Sung Noh Hong
- Department of Medicine, Samsung Medical Center, Seoul 06351, South Korea
| | - Young-Ho Kim
- Department of Medicine, Samsung Medical Center, Seoul 06351, South Korea
| | - Dong Kyung Chang
- Department of Medicine, Samsung Medical Center, Seoul 06351, South Korea
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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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Zhang J, Qi Z, Ou W, Mi X, Fang Y, Zhang W, Yang Z, Zhou Y, Lin X, Hou J, Yuan Z. Advances in the treatment of malignant ascites in China. Support Care Cancer 2024; 32:97. [PMID: 38200158 DOI: 10.1007/s00520-023-08299-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024]
Abstract
PURPOSE Malignant ascites (MA) often occurs in recurrent abdominal malignant tumors, and the large amount of ascites associated with cancerous peritonitis not only leads to severe abdominal distension and breathing difficulties, but also reduces the patient's quality of life and ability to resist diseases, which usually makes it difficult to carry out anti-cancer treatment. The exploration of MA treatment methods is also a key link in MA treatment. This article is going to review the treatment of MA, to provide details for further research on the treatment of MA, and to provide some guidance for the clinical treatment of MA. METHOD This review analyzes various expert papers and summarizes them to obtain the paper. RESULT There are various treatment methods for MA, including systemic therapy and local therapy. Among them, systemic therapy includes diuretic therapy, chemotherapy, immunotherapy, targeted therapy, anti angiogenic therapy, CAR-T, and vaccine. Local therapy includes puncture surgery, peritoneal vein shunt surgery, acellular ascites infusion therapy, radioactive nuclide intraperitoneal injection therapy, tunnel catheter, and intraperitoneal hyperthermia chemotherapy. And traditional Chinese medicine treatment has also played a role in enhancing efficacy and reducing toxicity to a certain extent. CONCLUSION Although there has been significant progress in the treatment of MA, it is still one of the clinical difficulties. Exploring the combination or method of drugs with the best therapeutic effect and the least adverse reactions to control MA is still an urgent problem to be solved.
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Affiliation(s)
- Junzi Zhang
- Changchun University of Chinese Medicine, Changchun, Jilin, China
| | - Zhaoxue Qi
- Department of Secretory Metabolism, The First Hospital of Jilin University, Changchun, China
| | - Wenjie Ou
- Changchun University of Chinese Medicine, Changchun, Jilin, China
| | - Xuguang Mi
- Department of Central Laboratory, Jilin Provincial People's Hospital, Changchun, China
| | - Yanqiu Fang
- Department of Tumor Comprehensive Therapy, Jilin Provincial People's Hospital, Changchun, China
| | - Wenqi Zhang
- Changchun University of Chinese Medicine, Changchun, Jilin, China
| | - Zhen Yang
- Changchun University of Chinese Medicine, Changchun, Jilin, China
| | - Ying Zhou
- Department of Tumor Comprehensive Therapy, Jilin Provincial People's Hospital, Changchun, China
| | - Xiuying Lin
- Department of Tumor Comprehensive Therapy, Jilin Provincial People's Hospital, Changchun, China
| | - Junjie Hou
- Department of Tumor Comprehensive Therapy, Jilin Provincial People's Hospital, Changchun, China.
| | - Zhixin Yuan
- Department of Emergency Surgery, Jilin Provincial People's Hospital, Changchun, China.
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12
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Uhlenbruch M, Bärmann MK, Bertram V, Krüger S. [Chylous ascites in NSCLC: It is not always malignant]. Pneumologie 2023; 77:1013-1015. [PMID: 37402387 DOI: 10.1055/a-2095-3180] [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: 07/06/2023]
Abstract
The etiology of chylous ascites is multifactorial. Malignant diseases, cirrhosis, trauma, lymphomatic abnormalities and mycobacteriosis are the most common causes. In NSCLC, chylous ascites is observed with peritoneal metastasis or abdominal lymph node metastases.RET alterations occur in 1-2% of NSCLC patients and since recently they can be treated in a targeted fashion.Our case report shows that new targeted therapies revolutionize prognosis, but confront us with the challenge of new and partly unknown side effects.
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Affiliation(s)
- Mark Uhlenbruch
- Pneumologie, Florence-Nightingale-Krankenhaus, Düsseldorf, Deutschland
| | | | - Volker Bertram
- Pneumologie, Florence-Nightingale-Krankenhaus, Düsseldorf, Deutschland
| | - Stefan Krüger
- Pneumologie, Florence-Nightingale-Krankenhaus, Düsseldorf, Deutschland
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13
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Tri TT, Duy HP, Thuan LNA, Kiet PT, Van Khanh NH, Nhi TTY, Tran NTT, Duc NM. Gallbladder perforation following trauma in an 18-month-old child with a common bile duct cyst. Radiol Case Rep 2023; 18:4528-4532. [PMID: 37868011 PMCID: PMC10587450 DOI: 10.1016/j.radcr.2023.09.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 09/23/2023] [Accepted: 09/26/2023] [Indexed: 10/24/2023] Open
Abstract
Gallbladder rupture caused by blunt abdominal trauma is an uncommon injury, particularly in children. This condition occurs even less frequently in children with common bile duct cysts. The history is difficult to obtain, the clinical symptoms are indistinct, and their assessment is obscured by a slew of other lesions. Radiography cannot produce clear images. Thus, the diagnosis is frequently delayed and confirmed only during surgery. Case reports of gallbladder injury after abdominal trauma are relatively rare and there are only 50 case reports in literature for 100 years. Herein, we present the case of an 18-month-old girl who had a ruptured gallbladder funnel due to blunt abdominal trauma caused by domestic violence, with an early clinical presentation of septic shock and chylous effusion. The patient underwent surgery after being diagnosed with chylous ascites that had not responded to medical treatment. Based on the findings, single-stage laparoscopic surgery is confirmed to aid in the diagnosis and treatment of gallbladder injury in the presence of a common bile duct cyst.
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Affiliation(s)
- Tran Thanh Tri
- Department of General Surgery, Children's Hospital 2, Ho Chi Minh City, Vietnam
| | - Ho Phi Duy
- Department of General Surgery, Children's Hospital 2, Ho Chi Minh City, Vietnam
| | - Luu-Nguyen An Thuan
- Department of General Surgery, Children's Hospital 2, Ho Chi Minh City, Vietnam
| | - Phan Tuan Kiet
- Department of General Surgery, Children's Hospital 2, Ho Chi Minh City, Vietnam
| | | | - Truong-Thi Yen Nhi
- Department of General Surgery, Children's Hospital 2, Ho Chi Minh City, Vietnam
| | - Nguyen-Thi Tuyen Tran
- Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Nguyen Minh Duc
- Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
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14
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Arya R, Kumar R, Kumar T, Kumar S, Anand U, Priyadarshi RN, Maji T. Prevalence and risk factors of lymphatic dysfunction in cirrhosis patients with refractory ascites: An often unconsidered mechanism. World J Hepatol 2023; 15:1140-1152. [PMID: 37970615 PMCID: PMC10642429 DOI: 10.4254/wjh.v15.i10.1140] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/14/2023] [Accepted: 10/08/2023] [Indexed: 10/24/2023] Open
Abstract
BACKGROUND The lymphatic system is crucial in maintaining the body fluid homeostasis. A dysfunctional lymphatic system may contribute to the refractoriness of ascites and edema in cirrhosis patients. Therefore, assessment of lymphatic dysfunction in cirrhosis patients with refractory ascites (RA) can be crucial as it would call for using different strategies for fluid mobilization. AIM To assessing the magnitude, spectrum, and clinical associations of lymphatic dysfunction in liver cirrhosis patients with RA. METHODS This observational study included 155 consecutive cirrhosis patients with RA. The presence of clinical signs of lymphedema, such as peau d'orange appearance and positive Stemmer sign, intestinal lymphangiectasia (IL) on duodenal biopsy seen as dilated vessels in the lamina propria with strong D2-40 immunohistochemistry, and chylous ascites were used to diagnose the overt lymphatic dysfunctions. RESULTS A total of 69 (44.5%) patients out of 155 had evidence of lymphatic dysfunction. Peripheral lymphedema, found in 52 (33.5%) patients, was the most common manifestation, followed by IL in 42 (27.0%) patients, and chylous ascites in 2 (1.9%) patients. Compared to patients without lymphedema, those with lymphedema had higher mean age, median model for end-stage liver disease scores, mean body mass index, mean ascitic fluid triglyceride levels, and proportion of patients with hypoproteinemia (serum total protein < 5 g/dL) and lymphocytopenia (< 15% of total leukocyte count). Patients with IL also had a higher prevalence of lymphocytopenia and hypoproteinemia (28.6% vs. 9.1%, P = 0.004). Seven (13%) patients with lymphedema had lower limb cellulitis compared to none in those without it. On multivariate regression analysis, factors independently associated with lymphatic dysfunction included obesity [odds ratio (OR): 4.2, 95% confidence intervals (95%CI): 1.1-15.2, P = 0.027], lymphocytopenia [OR: 6.2, 95%CI: 2.9-13.2, P < 0.001], and hypoproteinemia [OR: 3.7, 95%CI: 1.5-8.82, P = 0.003]. CONCLUSION Lymphatic dysfunction is common in cirrhosis patients with RA. Significant indicators of its presence include hypoproteinemia and lymphocytopenia, which are likely due to the loss of lymphatic fluid from the circulation. Future efforts to mobilize fluid in these patients should focus on methods to improve lymphatic drainage.
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Affiliation(s)
- Rahul Arya
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India.
| | - Tarun Kumar
- Department of Pathology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Sudhir Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Utpal Anand
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Rajeev Nayan Priyadarshi
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Tanmoy Maji
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
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15
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Takahashi S, Satoh K, Okuyama M, Hirasawa N, Nakae H. Hyperthyroidism With Non-chylous Ascites: A Case Report. Cureus 2023; 15:e46657. [PMID: 37942363 PMCID: PMC10628337 DOI: 10.7759/cureus.46657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2023] [Indexed: 11/10/2023] Open
Abstract
Ascites is the accumulation of fluid in the abdominal cavity and is commonly attributed to various etiologies, including portal hypertension and peritoneal diseases. Hyperthyroidism is rarely associated with ascites, which is typically chylous and accompanied by high central venous pressure. We present a unique case of a 57-year-old woman with untreated hyperthyroidism who manifested non-chylous ascites without evidence of high venous pressure. Initially presenting with left lower leg pain, the patient presented with leg edema, abdominal distention, and diarrhea. A range of diagnostic tests ruled out common etiologies of ascites, such as liver cirrhosis, renal impairment, heart failure, infection, and malignancy. Ascites was characterized by low triglyceride levels, while no evidence of high venous pressure was found. Notably, the patient showed decreased levels of rapid turnover proteins, suggesting hypercatabolism and insufficient protein synthesis due to hyperthyroidism. Upon the initiation of antithyroid therapy, the patient's symptoms markedly improved. In conclusion, this report highlights a rare manifestation of hyperthyroidism that resulted in non-chylous ascites without high venous pressure. This underscores the need to include hyperthyroidism in the differential diagnosis of unexplained ascites, particularly in cases in which classical hyperthyroid symptoms are absent.
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Affiliation(s)
- Shodai Takahashi
- Department of Hematology, Nephrology, and Rheumatology, Akita University Graduate School of Medicine, Akita, JPN
| | - Kasumi Satoh
- Department of Emergency and Critical Care Medicine, Akita University Graduate School of Medicine, Akita, JPN
| | - Manabu Okuyama
- Department of Emergency and Critical Care Medicine, Akita University Graduate School of Medicine, Akita, JPN
| | - Nobuhisa Hirasawa
- Department of Emergency and Critical Care Medicine, Akita University Graduate School of Medicine, Akita, JPN
| | - Hajime Nakae
- Department of Emergency and Critical Care Medicine, Akita University Graduate School of Medicine, Akita, JPN
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16
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Tsuzaka S, Aiyama T, Kamachi H, Kakisaka T, Orimo T, Nagatsu A, Asahi Y, Maeda T, Kamiyama T, Taketomi A. Lymphaticovenous anastomosis for treatment of refractory chylous ascites: A case report. Microsurgery 2023; 43:606-610. [PMID: 37016794 DOI: 10.1002/micr.31042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 01/17/2023] [Accepted: 03/09/2023] [Indexed: 04/06/2023]
Abstract
Chylous ascites, the leakage of lymphatic fluid into the abdominal cavity caused by lymphatic fluid stasis or lymphatic vessel damage, can be treated by lymphaticovenous anastomosis (LVA). We report rarely performed abdominal LVA to treat a case of refractory ascites possibly caused by ligation of the thoracic duct and pleurodesis in a man aged 60 years requiring weekly ascites drainage. Ligation was abandoned because the leakage site was not determined. The greater omentum (GO) was generally edematous and showed lymphatic effusion by gross appearance, and was considered suitable for LVA. We performed once LVA in the lymphatic vessels and veins of the GO using common microsurgical instrumentation and lateral anastomosis. Lymphatic vessels in the omentum were dilated to 2-3 mm, and LVA was simple. After LVA, GO edema improved. Postoperatively, the patient developed paralytic ileus, which improved within a few days, and the patient was discharged without any increase in ascites after starting to diet. One year post-surgery, there was no recurrence of ascites. LVA at the GO may be effective for the treatment of refractory chylous ascites because of its absorptive lymphatic draining capabilities and large transverse vessels.
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Affiliation(s)
- Shoichi Tsuzaka
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
| | - Takeshi Aiyama
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
| | - Hirofumi Kamachi
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
| | - Tatsuhiko Kakisaka
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
| | - Tatsuya Orimo
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
| | - Akihisa Nagatsu
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
| | - Yoh Asahi
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
| | - Taku Maeda
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Graduate School of Medicine, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
| | - Toshiya Kamiyama
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
| | - Akinobu Taketomi
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
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17
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Nepali A, Guragain A, Devkota K, Paudyal P, Prasad Rimal S, Kafle A, Jung Karki R, Kumari S, Shrestha R. Chylous ascites following retroperitoneal lymphadenectomy in a patient with recurrent dysgerminoma of ovary: A case report. Gynecol Oncol Rep 2023; 48:101221. [PMID: 37576351 PMCID: PMC10422095 DOI: 10.1016/j.gore.2023.101221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/26/2023] [Accepted: 06/04/2023] [Indexed: 08/15/2023] Open
Abstract
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.
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Affiliation(s)
- Amit Nepali
- B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | | | - Karun Devkota
- Department of Radiology, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Punam Paudyal
- Department of Pathology, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Surya Prasad Rimal
- Department of Obstetrics and Gynaecology, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Awaj Kafle
- Department of Urosurgery, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Rikesh Jung Karki
- Department of Urosurgery, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Shilpi Kumari
- Department of Nutrition, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Ramesh Shrestha
- Department of Obstetrics and Gynaecology, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
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Jafari A, Reihani H, Karbasian F, Darban B, Dehghani SM. Chylous ascites as a rare complication of abdominal trauma in a 7-year-old girl: A case report. Clin Case Rep 2023; 11:e7408. [PMID: 37405045 PMCID: PMC10315450 DOI: 10.1002/ccr3.7408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 12/06/2022] [Accepted: 05/02/2023] [Indexed: 07/06/2023] Open
Abstract
Key Clinical Message Abdominal trauma can be one of the causes of chylous ascites in pediatric cases, along with tuberculosis and malignancy. However, a definitive diagnosis is more reasonable to be done by excluding other causes. Abstract Chylous ascites (CA) is a rare type of ascites. Though it has high mortality and morbidity rates, which usually happen due to the rupture of lymph vessels into the peritoneal cavity. Congenital abnormalities, including lymphatic hypoplasia or dysplasia, are the most causes in pediatrics. CA following trauma in children is very rare, and to the best of our knowledge, there are very few reports in this regard. Here, we report a 7-year-old girl who was referred to our center with CA after a car accident.
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Affiliation(s)
- Anahita Jafari
- Gastroenterology and Hepatology Research CenterShiraz University of Medical SciencesShirazIran
| | - Hamid Reihani
- School of MedicineShiraz University of Medical SciencesShirazIran
| | - Fereshteh Karbasian
- Department of Pediatric Gastroenterology and HepatologyIran University of Medical SciencesTehranIran
| | - Behnaz Darban
- Department of Pediatric Gastroenterology and HepatologyIran University of Medical SciencesTehranIran
- Department of Pediatric GastroenterologyHormozgan University of Medical SciencesBandar AbbasIran
| | - Seyed Mohsen Dehghani
- Gastroenterology and Hepatology Research CenterShiraz University of Medical SciencesShirazIran
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19
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Zaman M, Ryncarz R, Chen A, Yildirim S, Iskhagi S, Saidi R, Bratslavsky G, Shahbazov R. Chylous Ascites After Robot-Assisted Laparoscopic Donor Nephrectomy: Is Early Surgical Intervention Necessary? EXP CLIN TRANSPLANT 2023; 21:397-407. [PMID: 37334687 DOI: 10.6002/ect.2023.0041] [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: 06/20/2023]
Abstract
OBJECTIVES Chylous ascites is a rare complication that may occur after living donor nephrectomy. The continuous loss of lymphatics, which carries a high risk of morbidity, may ensue in possible immunodeficiency and protein-calorie malnutrition. Here, we presented patients who developed chylous ascites after robotassisted living donor nephrectomy and reviewed the current literature of therapeutic strategies for chylous ascites. MATERIALS AND METHODS We reviewed the medical records of 424 laparoscopic living donor nephrectomies performed at a single transplant center; among these, we studied the records of 3 patients who developed chylous ascites following robot-assisted living donor nephrectomy. RESULTS Among 438 living donor nephrectomies, 359 (81.9%) were laparoscopic and 77 (18.1%) were by robotic assistance. In the 3 cases highlighted in our study, patient 1 did not respond to conservative therapy, which consisted of diet optimization, total parenteral nutrition, and octreotide (somatostatin). Patient 1 subsequently underwent robotic-assisted laparoscopy with suture ligation and clipping of leaking lymphatic vessels, allowing the chylous ascites to subside. Patient 2 similarly did not respond to conservative treatment and developed ascites. Despite initial improvement after wound interrogation and drainage, patient 2 had continued symptoms, resulting in diagnostic laparoscopy and repair of leaky channels leading to the cisterna chyli. Patient 3 developed chylous ascites 4 weeks postoperatively and received ultrasonographic-guided paracentesis by interventional radiology, with results showing an aspirate consistent with chyle. The patient's diet was optimized, allowing for initial improvement and eventual return to normal diet. CONCLUSIONS Our case series and literature review demonstrate the importance of early surgical intervention after failed conservative management for resolution of chylous ascites in patients after robotassisted donor laparoscopic nephrectomy.
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Affiliation(s)
- Muizz Zaman
- From the Department of Surgery, Division of Transplantation, SUNY Upstate Medical University, Syracuse, New York; the Choate Rosemary Hall, Wallingford, Connecticut
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20
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Gupta S, Mundasad B. Chylous Ascites Associated with Small Bowel Volvulus: Case Report on a Laparoscopic Diagnosis. Middle East J Dig Dis 2023; 15:139-140. [PMID: 37546511 PMCID: PMC10404085 DOI: 10.34172/mejdd.2023.334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 02/08/2023] [Indexed: 08/08/2023] Open
Abstract
This case describes a rare clinical situation of chylous ascites due to lymphatic obstruction in the setting of small bowel volvulus. A 32-year-old man presented with acute onset abdominal pain in the preceding 3 hours, associated with nausea and vomiting. He underwent a computed tomography (CT) scan which was concerning for an internal hernia involving the small bowel. On subsequent laparoscopy, milky fluid suggestive of chyle was found within the pelvis, along with a torted segment of the small bowel. The bowel was gently reduced with ease using atraumatic laparoscopic graspers. On closer examination, the mesenteric border of the torted small bowel had a white edge suggestive of lymphatic build-up. This case report highlights the pertinent clinical features associated with this clinical scenario, important for the laparoscopic gastrointestinal surgeon.
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Affiliation(s)
- Saksham Gupta
- Department of General Surgery, Armidale Hospital,226 Rusden Street, Armidale 2305, New South Wales, Australia
| | - Basavaraj Mundasad
- Department of General Surgery, Armidale Hospital,226 Rusden Street, Armidale 2305, New South Wales, Australia
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21
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Duletzke NT, Kiraly LN, Martindale RG. Chylothorax and chylous ascites: Overview, management, and nutrition. Nutr Clin Pract 2023; 38:557-563. [PMID: 36938719 DOI: 10.1002/ncp.10973] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 03/21/2023] Open
Abstract
Chyle leaks of any source or type can cause significant morbidity and mortality. Attention to the anatomy and physiology of the leak, followed by stepwise dietary and pharmacologic management, obviates the need for surgical intervention in a majority of patients. In this article, we review the importance, etiology, anatomy, diagnosis, nutrition and immunologic effects, and options for treatment of chylothorax and chylous ascites based on experience and prior literature. We propose a multidisciplinary approach to optimize these treatments including the primary surgical teams, pharmacists, and dietitians, with reoperation as a last resort to minimize the morbidity of this challenging complication.
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Affiliation(s)
- Nicholas T Duletzke
- Department of Surgery, Oregon Health and Science University, Oregon, Portland, USA
| | - Laszlo N Kiraly
- Department of Surgery, Oregon Health and Science University, Oregon, Portland, USA
| | - Robert G Martindale
- Department of Surgery, Oregon Health and Science University, Oregon, Portland, USA
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22
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Chyloperitoneum in Peritoneal Dialysis Secondary to Calcium Channel Blocker Use: Case Series and Literature Review. J Clin Med 2023; 12:jcm12051930. [PMID: 36902718 PMCID: PMC10003695 DOI: 10.3390/jcm12051930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 02/22/2023] [Accepted: 02/27/2023] [Indexed: 03/05/2023] Open
Abstract
Chyloperitoneum (chylous ascites) is a rare complication of peritoneal dialysis (PD). Its causes may be traumatic and nontraumatic, associated with neoplastic disease, autoimmune disease, retroperitoneal fibrosis, or rarely calcium antagonist use. We describe six cases of chyloperitoneum occurring in patients on PD as a sequel to calcium channel blocker use. The dialysis modality was automated PD (two patients) and continuous ambulatory PD (the rest of the patients). The duration of PD ranged from a few days to 8 years. All patients had a cloudy peritoneal dialysate, characterized by a negative leukocyte count and sterile culture tests for common germs and fungi. Except for in one case, the cloudy peritoneal dialysate appeared shortly after the initiation of calcium channel blockers (manidipine, n = 2; lercanidipine, n = 4), and cleared up within 24-72 h after withdrawal of the drug. In one case in which treatment with manidipine was resumed, peritoneal dialysate clouding reappeared. Though turbidity of PD effluent is due in most cases to infectious peritonitis, there are other differential causes including chyloperitoneum. Although uncommon, chyloperitoneum in these patients may be secondary to the use of calcium channel blockers. Being aware of this association can lead to prompt resolution by suspension of the potentially offending drug, avoiding stressful situations for the patient such as hospitalization and invasive diagnostic procedures.
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23
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Olaru A, Venkatachalapathy SV, James M, Martinez-Calle N. A case of idiopathic chylous ascites. Oxf Med Case Reports 2023; 2023:omad009. [PMID: 36860959 PMCID: PMC9969818 DOI: 10.1093/omcr/omad009] [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: 12/09/2022] [Revised: 01/01/2023] [Accepted: 01/03/2023] [Indexed: 03/03/2023] Open
Abstract
Chylous ascites is a rare condition found in 1 in 20 000 patients admitted to hospital with abdominal distention. It is caused by a limited number of pathologies but can, in rare situations, be idiopathic. Its management is difficult and usually involves correcting the primary pathology, making idiopathic chylous ascites particularly difficult to manage. We present a case of idiopathic chylous ascites extensively investigated over a period of several years. An incidental finding of B cell lymphoma was initially suspected to have been the primary cause of the ascites; however, after successful treatment of this condition, the patient's ascites did not resolve. Diagnostic difficulties and management are discussed and an overview of the diagnostic process is outlined through this case.
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Affiliation(s)
- Adina Olaru
- Correspondence address. Nottingham University Hospitals NHS Trust, Queen’s Medical Centre, Derby Road, Nottingham NG2 7UH, UK. Tel: 0115 924 9924; E-mail:
| | - Suresh V Venkatachalapathy
- Nottingham Digestive Diseases Centre (NDDC) and National Institute for Health Research (NIHR), Nottingham Biomedical Research Centre (BRC), Nottingham University and Nottingham University Hospitals NHS Trust, Queen’s Medical Centre, Nottingham, UK
| | - Martin James
- National Institute for Health Research (NIHR), Nottingham Biomedical Research Centre (BRC), Nottingham University and Nottingham University Hospitals NHS Trust, Queen’s Medical Centre, Nottingham, UK
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Sakai L, Aguilera P, Karmegam S. Acute Chylous Ascites Status Post Median Arcuate Ligament Syndrome Decompression: A Unique Case Report and Literature Review. Cureus 2023; 15:e35300. [PMID: 36968858 PMCID: PMC10037925 DOI: 10.7759/cureus.35300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 02/21/2023] [Indexed: 02/24/2023] Open
Abstract
Chylous ascites (CA) are a rare finding of triglyceride-rich peritoneal fluid within the abdominal cavity. Malignancy, cirrhosis, and trauma after abdominal surgery are the leading causes of CA in adults. Currently, there are no published guidelines on the management of CA. This report describes a case of an 18-year-old female presenting with abdominal pain and distention following median arcuate ligament syndrome (MALS) decompression. A computed tomography (CT) of the abdomen and pelvis showed large-volume ascites with normal hepatic morphology. Paracentesis and ascitic fluid studies were positive for milky fluid rich in triglyceride. Her recent history of MALS decompression revealed the cause of her acute CA to be a postoperative complication from her abdominal surgery. This case highlights the diverse etiology of ascites and the importance of a careful history and physical examination when evaluating adults with ascites.
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25
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Chylous Ascites: Reassessment of Diagnostic Criteria in Patients With Portal Hypertension. Am J Gastroenterol 2023; 118:364-366. [PMID: 36379155 DOI: 10.14309/ajg.0000000000002072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 10/06/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The triglyceride (TG) threshold for diagnosis of chylous ascites in patients with portal hypertension remains uncertain. METHODS Retrospective analysis of lipoprotein electrophoresis was conducted in 286 consecutive ascites samples. RESULTS Ascitic TG ≥ 81 mg/dL is 95.4% sensitive and 94.6% specific for chylous ascites diagnosed by the presence of significant chylomicron population. DISCUSSION The cutoff for chylous ascites diagnosis should be TG ≥ 81 mg/dL.
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Lympho-SPECT/CT as a Key Tool in the Management of a Patient with Chylous Ascites. Biomedicines 2023; 11:biomedicines11020282. [PMID: 36830819 PMCID: PMC9953622 DOI: 10.3390/biomedicines11020282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/11/2023] [Accepted: 01/17/2023] [Indexed: 01/21/2023] Open
Abstract
Chylous ascites is a rare form of ascites usually associated with cirrhosis, abdominal malignancies, surgeries or infections. We presented a case of chylous ascites after robotic laparoscopic prostatectomy (PLDN-RALP), in which the correct diagnosis was achieved by SPECT/CT lymphoscintigraphy. A 72-year-old male developed chylous ascites after surgery and underwent lymphoscintigraphy with radiolabeled albumin nanocolloids for the supplementary study of the lymph flow and to detect a possible site of leakage. The scintigraphic imaging demonstrated the abdominal effusion and lymph stasis in the left iliac region. The combination of planar imaging with SPECT/CT can resolve the assessment of chylous disorders.
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27
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Azmi JA, C Thambiah S, Lee YL, Zahari Sham SY, Abdul Hamid H, Samsudin IN. Milky ascitic fluid in a newborn. J Paediatr Child Health 2023; 59:185-187. [PMID: 36222293 DOI: 10.1111/jpc.16243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 09/27/2022] [Accepted: 09/28/2022] [Indexed: 01/14/2023]
Affiliation(s)
- Jannaltul A Azmi
- Department of Pathology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia.,Department of Pathology, Hospital Tengku Ampuan Rahimah, Klang, Malaysia
| | - Subashini C Thambiah
- Department of Pathology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Yee L Lee
- Department of Paediatrics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Siti Y Zahari Sham
- Department of Pathology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | | | - Intan N Samsudin
- Department of Pathology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
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28
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Park SH, Kim KY, Cho M, Kim HI, Hyung WJ, Kim YM. Chylous Ascites After Gastric Cancer Surgery: Risk Factors and Treatment Results. J Gastric Cancer 2023; 23:253-263. [PMID: 37129150 PMCID: PMC10154137 DOI: 10.5230/jgc.2023.23.e2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 10/26/2022] [Accepted: 10/28/2022] [Indexed: 01/09/2023] Open
Abstract
PURPOSE Although chylous ascites is a frequent complication of radical gastrectomy for gastric cancer, proper diagnostic criteria and optimal treatment strategies have not been established. This study aimed to identify the clinical features of chylous ascites and evaluate the treatment outcomes. MATERIALS AND METHODS We retrospectively analyzed the data of patients who underwent radical gastrectomy between 2013 and 2019. Diagnosis was made when milky fluid or elevated triglyceride levels (≥100 mg/dL) appeared in the drains without a preceding infection. The clinical features, risk factors, and treatment outcomes were assessed according to the initial treatment modalities for fasting and non-fasting groups. RESULTS Among the 7,388 patients who underwent radical gastrectomy for gastric cancer, 156 (2.1%) experienced chylous ascites. The median length of hospital stay was longer in patients with chylous ascites than in those without (median [interquartile range]: 8.0 [6.0-12.0] vs. 6.0 [5.0-8.0], P<0.001). Low body mass index (adjusted odds ratio [aOR]=0.9; P<0.001), advanced gastric cancer (aOR=1.51, P=0.024), open surgery (reference: laparoscopic surgery; aOR=1.87, P=0.003), and extent of surgical resection (reference: subtotal gastrectomy, total gastrectomy, aOR=1.5, P=0.029; proximal gastrectomy, aOR=2.93, P=0.002) were associated with the occurrence of chylous ascites. The fasting group (n=12) was hospitalized for a longer period than the non-fasting group (n=144) (15.0 [12.5-19.5] vs. 8.0 [6.0-10.0], P<0.001). There was no difference in grade III complication rate (16.7% vs. 4.2%, P=0.117) or readmission rate (16.7% vs. 11.1%, P=0.632) between the groups. CONCLUSIONS A fat-controlled diet and medication without fasting provided adequate initial treatment for chylous ascites after radical gastrectomy for gastric cancer.
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Affiliation(s)
- Sung Hyun Park
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- Gastric Cancer Center, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Ki-Yoon Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- Gastric Cancer Center, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Minah Cho
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- Gastric Cancer Center, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Hyoung-Il Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- Gastric Cancer Center, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Woo Jin Hyung
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- Gastric Cancer Center, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Yoo Min Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
- Gastric Cancer Center, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
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Muacevic A, Adler JR, Singh G, Farooq A, Hurairah A. Milky Ascites: A Diagnostic Dilemma. Cureus 2023; 15:e34008. [PMID: 36811040 PMCID: PMC9939078 DOI: 10.7759/cureus.34008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2023] [Indexed: 01/21/2023] Open
Abstract
Chylous ascites is a milky-appearing, triglyceride-rich fluid within the abdominal cavity. It is a rare finding that arises from the disruption of the lymphatic system and can be caused by a wide variety of pathologies. Here, we present a diagnostically challenging case of chylous ascites. In this article, we discuss the pathophysiology and various etiologies of chylous ascites, explore the diagnostic tools available, and highlight the management strategies implemented in this rare finding.
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30
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Suleman M, Mohamedali A, Sadiq A, Tendai J, Lodhia J. Chylous ascites: Our experience from a resource-limited setting. Int J Surg Case Rep 2022; 102:107828. [PMID: 36463689 PMCID: PMC9720556 DOI: 10.1016/j.ijscr.2022.107828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 11/23/2022] [Accepted: 11/30/2022] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE Chyle is a lipid-rich, milky-appearing fluid originating from lymph tissues. Chylous ascites is the collection of chyle in the peritoneal cavity and is a rare pathology. CASE PRESENTATION In this case report we share our experience of successfully managing chylous ascites conservatively from a resource-limited setting. CLINICAL DISCUSSION There are numerous causes hence management includes treating the cause. Generally responds well to conservative management however some cases require surgical intervention. CONCLUSION Ascitic tapping is an effective diagnostic and therapeutic tool is chylous ascites.
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Affiliation(s)
- Mujaheed Suleman
- Department of General Surgery, Kilimanjaro Christian Medical Centre, P.O. Box 3010, Moshi, Tanzania
| | - Abbas Mohamedali
- Department of General Surgery, Kilimanjaro Christian Medical Centre, P.O. Box 3010, Moshi, Tanzania
| | - Adnan Sadiq
- Faculty of Medicine, Kilimanjaro Christian Medical University College, P.O. Box 2240, Moshi, Tanzania,Department of Radiology, Kilimanjaro Christian Medical Centre, P.O. Box 3010, Moshi, Tanzania
| | - Joylene Tendai
- Department of General Surgery, Kilimanjaro Christian Medical Centre, P.O. Box 3010, Moshi, Tanzania
| | - Jay Lodhia
- Department of General Surgery, Kilimanjaro Christian Medical Centre, P.O. Box 3010, Moshi, Tanzania,Faculty of Medicine, Kilimanjaro Christian Medical University College, P.O. Box 2240, Moshi, Tanzania,Corresponding author at: Kilimanjaro Christian Medical Centre, P.O. Box 3010, Moshi, Tanzania.
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31
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Kim BS, Seo Y, Kang CM. Alternative management of intractable chylous ascites following robot-assisted pancreaticoduodenectomy of Viscum album sclerotherapy: a case report. KOREAN JOURNAL OF CLINICAL ONCOLOGY 2022; 18:78-82. [PMID: 36945246 PMCID: PMC9942760 DOI: 10.14216/kjco.22010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 12/14/2022] [Accepted: 12/15/2022] [Indexed: 12/31/2022]
Abstract
A patient showed signs of fever and Hemovac insertion site discharge 8 days after surgery and was admitted. Abdominal paracentesis found milky ascites with triglyceride levels of the peritoneal fluid as high as 1,603 g/mL. Diagnosed as chylous ascites, symptomatic therapy such as empirical antibodies and diuretics was administered with paracentesis before being discharged. The ascites volume increased again, and the patient was re-admitted. The patient was treated with orlistat, octreotide, total parenteral nutrition administration, ascites drainage, and diuretics. Ascites levels increased further and intraperitoneal Viscum was administered. Clear ascites was observed, and the patient was discharged. We reported a case where conventional treatment for chylous ascites that occurred after pancreaticoduodenectomy was shown to be ineffective while Viscum extracted from mistletoe was able to manage chylous ascites.
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Affiliation(s)
- Beom Soo Kim
- Yonsei University College of Medicine, Seoul,
Korea
| | - Youngbin Seo
- Yonsei University College of Medicine, Seoul,
Korea
| | - Chang Moo Kang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul,
Korea
- Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul,
Korea
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32
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Intranodal Ultrasound-Guided Percutaneous Methylene Blue Injection for the Identification of Leakage Point during Laparoscopic Repair of Refractory Chylous Ascites after Laparoscopic Lymphadenectomy for Kidney Cancer. Case Rep Urol 2022; 2022:3817554. [DOI: 10.1155/2022/3817554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/09/2022] [Accepted: 11/01/2022] [Indexed: 11/22/2022] Open
Abstract
Chylous ascites is an uncommon complication after surgery that can result in malnutrition and immunodeficiency. Therefore, surgical interventions are reserved for refractory patients, and the primary success factor for these interventions is locating the point of leakage, which is often tricky. We describe a case of a 56-year-old male with chylous ascites after laparoscopic radical nephrectomy and lumbo-aortic lymphadenectomy for kidney cancer. The patient was initially managed with dietary modifications and drainage placement. Afterward, lymphography with Lipiodol, percutaneous embolization of the leakage point, and total parenteral nutrition were established. Finally, the patient underwent laparoscopic repair after identifying the leakage point by injecting methylene blue through an inguinal node. Complete resolution was achieved, and no complications related to the procedure were recorded. Intranodal methylene blue injection can be an invaluable tool to identify the point of leakage in selected patients to improve the outcomes of surgical repair of refractory chylous ascites.
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33
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Kong PF, Xu YH, Lai ZH, Ma MZ, Duan YT, Sun B, Xu DZ. Novel management indications for conservative treatment of chylous ascites after gastric cancer surgery. World J Gastroenterol 2022; 28:6056-6067. [PMID: 36405388 PMCID: PMC9669821 DOI: 10.3748/wjg.v28.i42.6056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/15/2022] [Accepted: 10/26/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chylous ascites (CA) presents a challenge as a relatively common postoperative complication in gastric cancer (GC). Primary conservative therapy involved total parenteral nutrition, continuous low-pressure drainage, somatostatin, and a low-fat diet. Drainage tube (DT) clamping has been presented as a potential alternative conservative treatment for GC patients with CA.
AIM To propose novel conservative treatment strategies for CA following GC surgery.
METHODS The data of patients with CA after GC surgery performed at the Fudan University Shanghai Cancer Center between 2006 and 2021 were evaluated retrospectively.
RESULTS 53 patients underwent surgery for GC and exhibited postoperative CA during the study period. Postoperative hospitalization and time of DT removal showed a significant positive association (R2 = 0.979, P < 0.001). We further observed that delayed DT removal significantly extended the total and postoperative hospitalization, antibiotic usage duration, and hospitalization cost (postoperative hospitalization: 25.8 d vs 15.5 d, P < 0.001; total hospitalization: 33.2 d vs 24.7 d, P < 0.01; antibiotic usage duration: 10.8 d vs 6.2 d, P < 0.01; hospitalization cost: ¥9.2 × 104vs ¥6.5 × 104, P < 0.01). Multivariate analysis demonstrated that postoperative infection and antibiotic usage were independent factors for delayed DT removal. Furthermore, DT removal times were shorter in seven patients who underwent DT clamping (clamped DT vs normal group, 11.8 d vs 13.6 d, P = 0.047; clamped DT vs delayed group, 13.6 d vs 27.4 d, P < 0.001). In addition, our results indicated that removal of the DT may be possible after three consecutive days of drainage volumes less than 300 mL in GC patients with CA.
CONCLUSION Infection and antibiotic usage were vital independent factors that influenced delayed DT removal in patients with CA. Appropriate standards for DT removal can significantly reduce the duration of hospitalization. Furthermore, DT clamping might be a recommended option for conservative treatment of postoperative CA.
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Affiliation(s)
- Peng-Fei Kong
- Department of Gastric Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Yong-Hu Xu
- Department of Gastric Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Zhi-Hua Lai
- Department of the General Surgery, Suzhou Industrial Park Xinghai Hospital, Suzhou 215124, Jiangsu Province, China
| | - Ming-Zhe Ma
- Department of Gastric Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Yan-Tao Duan
- Department of Gastric Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Bo Sun
- Department of Gastric Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Da-Zhi Xu
- Department of Gastric Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China
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34
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Cheng X, Huang J, Yang A, Wang Q. Refractory ascites after laparoscopic cholecystectomy: a case report. BMC Surg 2022; 22:317. [PMID: 35978331 PMCID: PMC9386935 DOI: 10.1186/s12893-022-01758-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 08/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Laparoscopic cholecystectomy is a common surgical option for gallstone disease with minimal trauma and rapid recovery. Ascites is a relatively uncommon complication after laparoscopic cholecystectomy and is more frequently observed in patients with preoperative abnormal liver function. However, patients without underlying liver disease develop refractory ascites after laparoscopic cholecystectomy are rare. We report a case of massive ascites caused by lymphatic injury after laparoscopic cholecystectomy. CASE PRESENTATION A 63-year-old woman complained of abdominal discomfort and distension at the twelfth day after a laparoscopic cholecystectomy for gallbladder stones. Subsequently, the patient developed spontaneous bacterial peritonitis and a decreased output of urine. Abdominal computed tomography (CT) identified abdominal effusion. The patient received abdominocentesis and the volume of slightly turbid yellow ascites averaged 1500-2000 ml per day. The results of laboratory analysis of ascitic fluid showed the following: serum-ascites albumin-gradient (SAAG), 11-12 g/L; albumin, 11-14 g/L; triglycerides, 0.91 mmol/L. After the diuretic therapy, repeated large-volume paracentesis with albumin supplementation, administration of antibiotics and renal vasodilating medications, the patient's symptoms did not relieve. Lymphoscintigraphy found a small amount of radioactive filling in the abdominal cavity. The patient finally received surgery with detection and ligation of the lymphatic leak. The ascites disappeared and the patient recovered well. CONCLUSIONS For patients with atypical characteristics of chylous ascites, lymphoscintigraphy could help to localize and qualify the diagnosis. Surgical treatment could be considered when conservative treatment fails.
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Affiliation(s)
- Xiaoyun Cheng
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Jin Huang
- Department of Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Aiming Yang
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Qiang Wang
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
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35
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Nakano TA, Dori Y, Gumer L, Liptzin DR, Hill LRS, Kulungowski AM. How we approach pediatric congenital chylous effusions and ascites. Pediatr Blood Cancer 2022; 69 Suppl 3:e29246. [PMID: 36070215 DOI: 10.1002/pbc.29246] [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: 04/23/2021] [Revised: 06/19/2021] [Accepted: 06/27/2021] [Indexed: 11/10/2022]
Abstract
Congenital lymphatic leak may develop in patients with maldeveloped lymphatics and result in life-threatening fluid and electrolyte imbalance, protein deficiency, and immunodeficiency. Rapid diagnosis and therapy are necessary to prevent these complications; however, the field lacks clinical trials to support standardized diagnostic treatment guidelines. We present our current multidisciplinary approach to the diagnosis and management of congenital lymphatic leak including chylous pleural effusions and ascites. Depending on the rate of lymphatic leak, therapy can range from observation with nutritional modifications to surgical and interventional procedures aimed to reduce lymphatic drainage. Modalities to image central and peripheral lymphatics have advanced considerably. Genetic variants and subsequent targets that drive lymphatic maldevelopment have expanded the repertoire of possible pharmacotherapeutic options.
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Affiliation(s)
- Taizo A Nakano
- Vascular Anomalies Center, Children's Hospital Colorado, Aurora, Colorado, USA.,Center for Cancer and Blood Disorders, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Yoav Dori
- Division of Cariology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Lindsey Gumer
- Division of Pediatric Gastroenterology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Deborah R Liptzin
- Breathing Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Lauren R S Hill
- Vascular Anomalies Center, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Ann M Kulungowski
- Vascular Anomalies Center, Children's Hospital Colorado, Aurora, Colorado, USA.,Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
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36
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Uchihara M, Ehara J, Iwanami K, Kitamura K, Suzuki T, Ishizuka N, Yamada T, Hiraoka E. Chylous Ascites Due to Hyperthyroidism and Heart Failure. Intern Med 2022; 61:1995-1998. [PMID: 34897150 PMCID: PMC9334248 DOI: 10.2169/internalmedicine.7873-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Chylous ascites (CA) is the accumulation of fluid with a high triglyceride content in the peritoneal cavity. Only two cases in the literature have reported CA with hyperthyroidism. A 28-year-old previously healthy woman presented with gradual-onset abdominal swelling, exertional dyspnea, and diarrhea. Hyperthyroidism and heart failure were diagnosed using laboratory investigation and echocardiography. Ultrasonography revealed a large amount of ascites. The ascitic fluid was milky with elevated triglyceride levels. Treatment with anti-thyroid therapy and diuretics improved all symptoms, and the free triiodothyronine (T3) level normalized after five days. Hyperthyroidism and heart failure should be considered as reversible causes of CA.
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Affiliation(s)
- Masaki Uchihara
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Japan
- Department of Professional Development, Tokyo Medical and Dental University Hospital, Japan
| | - Jun Ehara
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Japan
- Department of Pulmonary Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Japan
| | - Keiichi Iwanami
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Japan
- Department of Rheumatology, Tokyo Bay Urayasu Ichikawa Medical Center, Japan
| | - Koichi Kitamura
- Department of Nephrology, Endocrinology and Diabetes, Tokyo Bay Urayasu Ichikawa Medical Center, Japan
| | - Toshihiko Suzuki
- Department of Nephrology, Endocrinology and Diabetes, Tokyo Bay Urayasu Ichikawa Medical Center, Japan
| | - Noriyoshi Ishizuka
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Japan
| | - Toru Yamada
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Japan
- Department of Family Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Eiji Hiraoka
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Japan
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37
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Ilagan-Ying YC, Park EY, Lam R, Gupta S. Pancreatic Neuroendocrine Tumor Presenting with Chylous Ascites: Multidisciplinary Workup to Differentiate from Malignant Ascites. J Gen Intern Med 2022; 37:2082-2085. [PMID: 35260958 PMCID: PMC9198176 DOI: 10.1007/s11606-022-07463-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 02/07/2022] [Indexed: 10/25/2022]
Affiliation(s)
- Ysabel C Ilagan-Ying
- Section of General Internal Medicine, Yale School of Medicine, West Haven, CT, USA
| | | | - Robert Lam
- Section of General Internal Medicine, Yale School of Medicine, West Haven, CT, USA
| | - Shaili Gupta
- Section of General Internal Medicine, Yale School of Medicine, West Haven, CT, USA.
- Department of Medicine, Veterans Affairs (VA) Connecticut Healthcare System, West Haven, CT, USA.
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38
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Pinto JC, Oliveira S, Duarte L, Ferreira M, Marques C, Casimiro C. Chyloperitoneum due to gastric carcinoma: a case report. Oxf Med Case Reports 2022; 2022:omac062. [PMID: 35769185 PMCID: PMC9235027 DOI: 10.1093/omcr/omac062] [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: 11/08/2021] [Revised: 05/02/2022] [Accepted: 05/03/2022] [Indexed: 11/12/2022] Open
Abstract
Chyloperitoneum is a rare manifestation of gastric carcinoma, generally occurring late in the course of the disease with a poor prognosis. We report an unusual case of chyloperitoneum in a patient with gastric carcinoma. A 61-year-old male patient presented with postprandial fullness, nausea and weight loss. The upper gastrointestinal endoscopy demonstrated a stenosing lesion of the esophagogastric junction. A biopsy was made and revealed a signet-ring cell gastric adenocarcinoma. The staging CT scan showed multiple abdominal lymphadenopathies and mild ascites. The patient underwent a staging laparoscopy that revealed a large carcinoma of the gastric cardia and a milky-appearing peritoneal fluid. A peritoneal washing and abdominal drainage were performed. The fluid analysis showed a high concentration of triglycerides, compatible with a chyloperitoneum. The patient started medium chain triglycerides-based diet with good response. This case report emphasizes that chyloperitoneum should be considered when assessing patients with gastric carcinoma.
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Affiliation(s)
- J C Pinto
- Serviço de Cirurgia Geral , Centro Hospitalar Tondela Viseu EPE, Viseu, Portugal
| | - S Oliveira
- Serviço de Cirurgia Geral , Centro Hospitalar Tondela Viseu EPE, Viseu, Portugal
| | - L Duarte
- Serviço de Cirurgia Geral , Centro Hospitalar Tondela Viseu EPE, Viseu, Portugal
| | - M Ferreira
- Serviço de Cirurgia Geral , Centro Hospitalar Tondela Viseu EPE, Viseu, Portugal
| | - C Marques
- Serviço de Cirurgia Geral , Centro Hospitalar Tondela Viseu EPE, Viseu, Portugal
| | - C Casimiro
- Serviço de Cirurgia Geral , Centro Hospitalar Tondela Viseu EPE, Viseu, Portugal
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Sakamoto S, Takata N, Noda Y, Ozaki K, Okabayashi T. Postoperative chylous ascites after total gastrectomy successfully treated using peritoneovenous (Denver) shunt: a case report. Surg Case Rep 2022; 8:92. [PMID: 35534589 PMCID: PMC9086017 DOI: 10.1186/s40792-022-01447-0] [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: 04/04/2022] [Accepted: 05/05/2022] [Indexed: 11/24/2022] Open
Abstract
Background Chylous ascites (CA) is a rare complication of gastrectomy for gastric cancer. While most cases of postoperative CA improve with medication or nutritional support, some are refractory to conservative treatment. A peritoneovenous shunt (PVS) may help patients who are poor candidates for surgery. However, PVS placement for postoperative CA after gastroenterological surgery has been rarely reported. Herein, we present a case of postoperative CA following total gastrectomy with para-aortic lymphadenectomy, treated successfully by PVS placement. Case presentation A 74-year-old man who underwent total gastrectomy with para-aortic lymph node dissection was hospitalised because of insufficient oral intake and dehydration. His abdomen was markedly distended with severe bilateral lower extremity oedema. On admission, abdominal computed tomography (CT) showed a high volume of ascites and no signs of cancer recurrence. Accordingly, postoperative CA resulting from drainage of fluid on paracentesis was diagnosed. Despite nutritional support, diuretics, and octreotide administration, his abdominal distension and nutritional status did not improve. We could not identify the sites of lymphatic leakage in the three intranodal lymphangiographies followed by CT. Although we considered a surgical treatment in our patient, we decided against it. Because we could not identify lymphatic leakage site during lymphangiography, surgical treatment might have a potential failure of detection and closure of leakage site. Furthermore, the patient’s general condition was poor because of malnutrition resulting from the loss of lymphatic fluid. Consequently, we decided to place PVS. After PVS placement, his abdominal distension improved rapidly, and he was discharged without serious complications. Thirteen months after PVS, patient has no relapse of abdominal distention and nutrition status has improved. Conclusion PVS might be a good option to manage refractory postoperative CA, as the leakage point cannot be detected on lymphangiography.
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Lu C, Wang L, Gao Q. Chylous ascites with lymphatic leakage localization: technical aspects and clinical applications. BMC Surg 2022; 22:158. [PMID: 35524233 PMCID: PMC9077892 DOI: 10.1186/s12893-022-01619-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 04/25/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Carbon nanoparticle suspension (CNS) was applied to locate the lymphatic leakage in chylous ascites (CA). However, the flow speed and distance of the CNS were particularly decreased in the following two cases (patient 5 and 6). This study aimed to investigate and improve the flow speed and distance of the CNS via a rat model. METHODS Seven patients with CA were accepted for surgery in the past two years. Clinical data were recorded. Rats were divided into two groups to confirm the hypothesis regarding whether accepting milk or orally administered food before surgery was the key factor in CA surgery with CNS. The animals were divided into 2 groups: experimental group of 5 rats receiving fat emulsion injection (2 g/kg) 30 min before the operation and control group of 5 rats receiving saline. We analyzed flow speed and distance of the CNS in two groups of rats. The hypothesis established was that CNS movements pattern differ depending on the degree of capillary lymph duct filling. Finally, the late case reconfirmed the hypothesis again. RESULTS In animal experiments, the CNS in the preoperative high-fat feeding group moved faster and over a longer distance than that in the control group (0.51 ± 0.09 cm vs. 0.19 ± 0.10 cm, respectively; p < 0.05). Based on this, the CNS was applied to the seventh patient, who had been given a diet with a slightly higher fat content 3 days before the operation, and marked improvement with a complete cure was recorded. CONCLUSIONS The capillary lymph duct was beginning to swell after dietary intake. The dilation of the lymph vessel could make it easier for the CNS to move and reach the leakage.
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Affiliation(s)
- Chaoxiang Lu
- Department of Neonatal Surgery, Xi'an Children's Hospital & The Affiliated Children Hospital of Xi'an Jiaotong University, No. 69, Xijuyuan Lane ,Lianhu District, Xi'an, Shaanxi, 710003, China
| | - Lei Wang
- Department of Neonatal Surgery, Xi'an Children's Hospital & The Affiliated Children Hospital of Xi'an Jiaotong University, No. 69, Xijuyuan Lane ,Lianhu District, Xi'an, Shaanxi, 710003, China
| | - Qi Gao
- Department of Neonatal Surgery, Xi'an Children's Hospital & The Affiliated Children Hospital of Xi'an Jiaotong University, No. 69, Xijuyuan Lane ,Lianhu District, Xi'an, Shaanxi, 710003, China.
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Uno K, Iyoshi S, Yoshihara M, Kitami K, Mogi K, Fujimoto H, Sugiyama M, Koya Y, Yamakita Y, Nawa A, Kanayama T, Tomita H, Enomoto A, Kajiyama H. Metastatic Voyage of Ovarian Cancer Cells in Ascites with the Assistance of Various Cellular Components. Int J Mol Sci 2022; 23:4383. [PMID: 35457198 PMCID: PMC9031612 DOI: 10.3390/ijms23084383] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 04/10/2022] [Accepted: 04/12/2022] [Indexed: 12/16/2022] Open
Abstract
Epithelial ovarian cancer (EOC) is the most lethal gynecologic malignancy and has a unique metastatic route using ascites, known as the transcoelomic root. However, studies on ascites and contained cellular components have not yet been sufficiently clarified. In this review, we focus on the significance of accumulating ascites, contained EOC cells in the form of spheroids, and interaction with non-malignant host cells. To become resistant against anoikis, EOC cells form spheroids in ascites, where epithelial-to-mesenchymal transition stimulated by transforming growth factor-β can be a key pathway. As spheroids form, EOC cells are also gaining the ability to attach and invade the peritoneum to induce intraperitoneal metastasis, as well as resistance to conventional chemotherapy. Recently, accumulating evidence suggests that EOC spheroids in ascites are composed of not only cancer cells, but also non-malignant cells existing with higher abundance than EOC cells in ascites, including macrophages, mesothelial cells, and lymphocytes. Moreover, hetero-cellular spheroids are demonstrated to form more aggregated spheroids and have higher adhesion ability for the mesothelial layer. To improve the poor prognosis, we need to elucidate the mechanisms of spheroid formation and interactions with non-malignant cells in ascites that are a unique tumor microenvironment for EOC.
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Affiliation(s)
- Kaname Uno
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Nagoya University, Nagoya 466-8560, Japan; (K.U.); (S.I.); (K.K.); (K.M.); (H.F.); (Y.Y.); (H.K.)
- Division of Clinical Genetics, Department of Laboratory Medicine, Lund University, 223-62 Lund, Sweden
| | - Shohei Iyoshi
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Nagoya University, Nagoya 466-8560, Japan; (K.U.); (S.I.); (K.K.); (K.M.); (H.F.); (Y.Y.); (H.K.)
- Spemann Graduate School of Biology and Medicine, University of Freiburg, 79104 Freiburg, Germany
| | - Masato Yoshihara
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Nagoya University, Nagoya 466-8560, Japan; (K.U.); (S.I.); (K.K.); (K.M.); (H.F.); (Y.Y.); (H.K.)
| | - Kazuhisa Kitami
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Nagoya University, Nagoya 466-8560, Japan; (K.U.); (S.I.); (K.K.); (K.M.); (H.F.); (Y.Y.); (H.K.)
| | - Kazumasa Mogi
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Nagoya University, Nagoya 466-8560, Japan; (K.U.); (S.I.); (K.K.); (K.M.); (H.F.); (Y.Y.); (H.K.)
| | - Hiroki Fujimoto
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Nagoya University, Nagoya 466-8560, Japan; (K.U.); (S.I.); (K.K.); (K.M.); (H.F.); (Y.Y.); (H.K.)
- Discipline of Obstetrics and Gynecology, Adelaide Medical School, Robinson Research Institute, University of Adelaide, Adelaide 5005, Australia
| | - Mai Sugiyama
- Bell Research Center, Department of Obstetrics and Gynecology Collaborative Research, Graduate School of Medicine, Nagoya University, Nagoya 466-8560, Japan; (M.S.); (Y.K.); (A.N.)
| | - Yoshihiro Koya
- Bell Research Center, Department of Obstetrics and Gynecology Collaborative Research, Graduate School of Medicine, Nagoya University, Nagoya 466-8560, Japan; (M.S.); (Y.K.); (A.N.)
| | - Yoshihiko Yamakita
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Nagoya University, Nagoya 466-8560, Japan; (K.U.); (S.I.); (K.K.); (K.M.); (H.F.); (Y.Y.); (H.K.)
- Bell Research Center, Department of Obstetrics and Gynecology Collaborative Research, Graduate School of Medicine, Nagoya University, Nagoya 466-8560, Japan; (M.S.); (Y.K.); (A.N.)
| | - Akihiro Nawa
- Bell Research Center, Department of Obstetrics and Gynecology Collaborative Research, Graduate School of Medicine, Nagoya University, Nagoya 466-8560, Japan; (M.S.); (Y.K.); (A.N.)
| | - Tomohiro Kanayama
- Department of Tumor Pathology, Graduate School of Medicine, Gifu University, Gifu 501-1194, Japan; (T.K.); (H.T.)
| | - Hiroyuki Tomita
- Department of Tumor Pathology, Graduate School of Medicine, Gifu University, Gifu 501-1194, Japan; (T.K.); (H.T.)
| | - Atsushi Enomoto
- Department of Pathology, Graduate School of Medicine, Nagoya University, Nagoya 466-8560, Japan;
| | - Hiroaki Kajiyama
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Nagoya University, Nagoya 466-8560, Japan; (K.U.); (S.I.); (K.K.); (K.M.); (H.F.); (Y.Y.); (H.K.)
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Gritsiuta AI, Bracken A, Lara-Gutierrez J, Gilleland WN. Sit-ups and emergency abdominal surgery: a rare case of intestinal volvulus and resultant chylous ascites incited by abdominal exercises. J Surg Case Rep 2022; 2022:rjac155. [DOI: 10.1093/jscr/rjac155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 03/22/2022] [Indexed: 11/12/2022] Open
Abstract
Abstract
Chylous ascites is a unique phenomenon defined in the literature by ascitic fluid with a triglyceride content >200 mg/dl. This rather rare entity can be associated with a number of different pathologies related to abnormalities within the lymphatic system. This case report serves to demonstrate an intestinal volvulus and resultant chylous ascites found on exploratory laparotomy in an otherwise healthy individual who participated in routine, extreme abdominal exercises.
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Affiliation(s)
- Andrei I Gritsiuta
- Department of Surgical Services, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Alexander Bracken
- Department of Surgical Services, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jorge Lara-Gutierrez
- Department of Surgical Services, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - William N Gilleland
- Department of Surgical Services, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Abstract
PURPOSE OF REVIEW Gastrointestinal failure is a polymorphic syndrome with multiple causes. Managing the different situations from a practical, metabolic, and nutritional point of view is challenging, which the present review will try to address. RECENT FINDINGS Acute gastrointestinal injury (AGI) has been defined and has evolved into a concept of gastrointestinal dysfunction score (GIDS) built on the model of Sequential Organ Failure Assessment (SOFA) score, and ranging from 0 (no risk) to 4 (life threatening). But there is yet no specific, reliable and reproducible, biomarker linked to it. Evaluating the risk with the Nutrition Risk Screening (NRS) score is the first step whenever addressing nutrition therapy. Depending on the severity of the gastrointestinal failure and its clinical manifestations, nutritional management needs to be individualized but always including prevention of undernutrition and dehydration, and administration of target essential micronutrients. The use of fibers in enteral feeding solutions has gained acceptance and is even recommended based on microbiome findings. Parenteral nutrition whether alone or combined to enteral feeding is indicated whenever the intestine is unable to process the needs. SUMMARY The heterogeneity of gastrointestinal insufficiency precludes a uniform nutritional management of all critically ill patients but justifies its early detection and the implementation of individualized care.
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Affiliation(s)
- Mette M Berger
- Service of Adult Intensive Care, Lausanne University Hospital (CHUV), Lausanne, Switzerland
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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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Kalia S, Narkhede A, Yadav AK, Bhalla AK, Gupta A. Retrograde transvenous selective lymphatic duct embolization in post donor nephrectomy chylous ascites. CEN Case Rep 2022; 11:1-5. [PMID: 34218419 PMCID: PMC8811106 DOI: 10.1007/s13730-021-00618-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 06/15/2021] [Indexed: 12/20/2022] Open
Abstract
Chylous ascites is a rare, potentially sinister complication in post donor nephrectomy patients which may cause significant morbidity in form of severe malnutrition and an immuno-compromised state. We present two patients with post donor nephrectomy-related chylous leaks who failed conservative treatment. In both cases, lymphangiography was done first to detect the chylous leak site in the left renal fossa, and thereafter transvenous retrograde approach via left subclavian vein with selective lymphatic duct embolization of chylous leak was done with coils and glue successfully. Chylous ascites resolved in both patients after the embolization. Hence retrograde transvenous embolization technique appears to be an effective management option for refractory chylous leaks.
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Affiliation(s)
- Shekhar Kalia
- Department of Interventional Radiology, Sir Ganga Ram Hospital, New Delhi, India
| | - Amey Narkhede
- Department of Interventional Radiology, Sir Ganga Ram Hospital, New Delhi, India
| | - Ajit Kumar Yadav
- Department of Interventional Radiology, Sir Ganga Ram Hospital, New Delhi, India.
| | | | - Arun Gupta
- Department of Interventional Radiology, Sir Ganga Ram Hospital, New Delhi, India
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46
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Parshin VD, Saliba MB, Anokhina VM, Bolotskaya AA, Kryuchkova KY, Parshin AV. [Surgery for chyloptysis]. Khirurgiia (Mosk) 2022:120-125. [PMID: 35593636 DOI: 10.17116/hirurgia2022051120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Chyloptysis is a rare disease characterized by formation of bronchial casts containing chyle and repeating bronchial tree branching. The authors report a 56-year-old woman with chyloptysis accompanied by cough and expectoration of milky bronchial casts, as well several episodes of asphyxia. Stages of diagnosis and successful treatment including thoracic duct ligation and skeletonization of the root of the left lung are described. The authors also analyze literature data on etiology, pathogenesis and feasibility of conservative and surgical treatment of these patients.
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Affiliation(s)
- V D Parshin
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - M B Saliba
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - V M Anokhina
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - A A Bolotskaya
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - K Yu Kryuchkova
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - A V Parshin
- Sechenov First Moscow State Medical University, Moscow, Russia
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Necrotizing enterocolitis as a side effect of octreotide in a preterm neonate, a case report. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2021.102136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Zheng HD, Liu YR, Chen ZZ, Sun YF, Xu CH, Xu JH. Nomogram for predicting chylous ascites after right colectomy. World J Gastrointest Surg 2021; 13:1361-1371. [PMID: 34950426 PMCID: PMC8649560 DOI: 10.4240/wjgs.v13.i11.1361] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/01/2021] [Accepted: 09/17/2021] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Hui-Da Zheng
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou 362000, Fujian Province, China
| | - Yu-Rong Liu
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou 362000, Fujian Province, China
| | - Zhen-Ze Chen
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou 362000, Fujian Province, China
| | - Ya-Feng Sun
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou 362000, Fujian Province, China
| | - Chun-Hao Xu
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou 362000, Fujian Province, China
| | - Jian-Hua Xu
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou 362000, Fujian Province, China
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Thibault R, Abbasoglu O, Ioannou E, Meija L, Ottens-Oussoren K, Pichard C, Rothenberg E, Rubin D, Siljamäki-Ojansuu U, Vaillant MF, Bischoff SC. ESPEN guideline on hospital nutrition. Clin Nutr 2021; 40:5684-5709. [PMID: 34742138 DOI: 10.1016/j.clnu.2021.09.039] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 09/17/2021] [Indexed: 12/16/2022]
Abstract
In hospitals through Europe and worldwide, the practices regarding hospital diets are very heterogeneous. Hospital diets are rarely prescribed by physicians, and sometimes the choices of diets are based on arbitrary reasons. Often prescriptions are made independently from the evaluation of nutritional status, and without taking into account the nutritional status. Therapeutic diets (low salt, gluten-free, texture and consistency modified, …) are associated with decreased energy delivery (i.e. underfeeding) and increased risk of malnutrition. The European Society for Clinical Nutrition and Metabolism (ESPEN) proposes here evidence-based recommendations regarding the organization of food catering, the prescriptions and indications of diets, as well as monitoring of food intake at hospital, rehabilitation center, and nursing home, all of these by taking into account the patient perspectives. We propose a systematic approach to adapt the hospital food to the nutritional status and potential food allergy or intolerances. Particular conditions such as patients with dysphagia, older patients, gastrointestinal diseases, abdominal surgery, diabetes, and obesity, are discussed to guide the practitioner toward the best evidence based therapy. The terminology of the different useful diets is defined. The general objectives are to increase the awareness of physicians, dietitians, nurses, kitchen managers, and stakeholders towards the pivotal role of hospital food in hospital care, to contribute to patient safety within nutritional care, to improve coverage of nutritional needs by hospital food, and reduce the risk of malnutrition and its related complications.
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Affiliation(s)
- Ronan Thibault
- Unité de Nutrition, CHU Rennes, INRAE, INSERM, Univ Rennes, Nutrition Metabolisms and Cancer Institute, NuMeCan, Rennes, France.
| | - Osman Abbasoglu
- Department of Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Elina Ioannou
- Department of Nutrition, Limassol General Hospital, Cyprus
| | - Laila Meija
- Riga Stradins University, Pauls Stradins Clinical University Hospital, Latvia
| | - Karen Ottens-Oussoren
- Department of Nutrition and Dietetics, Amsterdam University Medical Centers, Location VUmc, Amsterdam, the Netherlands
| | - Claude Pichard
- Unité de Nutrition, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Elisabet Rothenberg
- Faculty of Health Sciences Kristianstad University Kristianstad Sweden, Sweden
| | - Diana Rubin
- Vivantes Netzwerk für Gesundheit GmbH, Humboldt Klinikum und Klinikum Spandau, Berlin, Germany
| | | | | | - Stephan C Bischoff
- University of Hohenheim, Institute of Nutritional Medicine, Stuttgart, Germany
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50
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Jagannathan SH, Winn CM, Nayar AP, Koussa GJ, Brenner CA. Sarcoidosis with secondary recurrent right-sided chylothorax and chylous ascites in a Caucasian male patient. Oxf Med Case Reports 2021; 2021:omab098. [PMID: 34729197 PMCID: PMC8557417 DOI: 10.1093/omcr/omab098] [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: 05/13/2021] [Revised: 07/21/2021] [Accepted: 08/29/2021] [Indexed: 11/20/2022] Open
Abstract
Sarcoidosis is a rare multisystem autoimmune disease characterized by the presence of non-caseating granulomas in involved organs. We report a novel case of a 61-year-old Caucasian male with sarcoidosis presenting with recurrent chylothorax and chylous ascites. Pleural and ascitic fluid analysis revealed high triglyceride levels, consistent with chylothorax and chylous ascites, respectively. Common etiologies of chylous fluid such as thoracic duct surgical trauma, malignancy and infection were all excluded. Sarcoidosis was confirmed by the presence of non-caseating granulomas on a mediastinal lymph node biopsy. Conservative treatment with low-fat diet, prednisone, octreotide and multiple thoracenteses failed to effectively resolve the chylothorax. Surgical interventions with pleurodesis and thoracic duct ligation were performed, leading to the complete resolution of the chylous effusion and ascites.
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Affiliation(s)
| | - Caleb M Winn
- College of Osteopathic Medicine, University of New England, Biddeford, ME 04005, USA
| | - Arun P Nayar
- College of Osteopathic Medicine, University of New England, Biddeford, ME 04005, USA
| | - Ghassan J Koussa
- Department of Pulmonology & Critical Care Medicine, St. Luke's Medical Center, Utica, NY 13502, USA
| | - Carol A Brenner
- Department of Biomedical Sciences, College of Osteopathic Medicine, University of New England, Biddeford, ME 04005, USA
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