Chylous ascites in colorectal surgery: A systematic review

Successful outpatient conservative management of chyle leak after laparoscopic left hemicolectomy

Chyle leak is a pathological extravasation of chyle into the peritoneal cavity after a surgical injury. It is an uncommon complication in colorectal surgery. In most cases, conservative treatment is effective, although it often entails prolonged hospital stays. We present the case of a 60-year-old female with chyle leak after laparoscopic left hemicolectomy with complete mesocolic excision who underwent successful outpatient conservative management. We found no other cases of successful conservative outpatient treatment in the consulted literature. Adequate outpatient management may provide significant benefits by reducing hospital costs and improving patient´s quality of life, while maintaining the possibility of starting adjuvant treatment if indicated.

Incomplete lymphatic sealing around the inferior mesenteric artery is a risk factor for chylous ascites in robotic rectal cancer surgery

INTRODUCTION

Compared with laparoscopic surgery (LS), robotic surgery (RS) is considered to have acceptable outcomes in rectal cancer, but few reports have focused on chylous ascites in RS. The aim of this study was to investigate the incidence and etiology of chylous ascites after RS.

METHODS

This retrospective study included 291 patients with rectal cancer who underwent RS (n = 165) or LS (n = 126) with high ligation of the inferior mesenteric artery (IMA). Propensity score matching (PSM) was performed to compare the two groups.

RESULTS

\Dissection around the IMA was achieved using ultrasonic coagulating shears in most LS cases, and monopolar scissors in most RS cases, sometimes using bipolar vessel sealing device or bipolar forceps. The incidence of chylous ascites was 12.2% in RS and 4.1% in LS after PSM (P = .037). When limited to the RS group, multivariate analysis identified absence of lymphatic sealing at the left side of the IMA and shorter operative time as independent risk factors for chylous ascites. Except for duration of drain placement, no outcomes differed significantly with or without chylous ascites. One patient with chylous ascites developed later infection and required antibiotic treatment.

CONCLUSION

The incidence of chylous ascites is significantly higher in RS than in LS, and RS with incomplete lymphatic sealing around the IMA is a risk factor for chylous ascites in rectal cancer. Although outcomes for patients with chylous ascites were acceptable, adequate lymphatic sealing during dissection around the IMA is crucial to prevent chylous ascites in RS.

Lymphatic Interventions in the Cancer Patient

PURPOSE OF REVIEW

The incidence of lymphatic leakage (iatrogenic and non-iatrogenic) is growing in cancer population due to the increased complexity of the surgical procedures and improved overall survival in cancer patients. The purpose of this article is to review the contemporary approach in the field of percutaneous lymphatic embolization in cancer patients with lymphatic leaks.

RECENT FINDINGS

Since the advent of intranodal lymphangiography in 2011 alongside with the MR and CT lymphangiography, the accuracy of diagnosis of the lymphatic diseases has significantly improved significantly. These advancements have triggered a revival of minimally invasive lymphatic interventions. Lymphatic embolization is expanding from the classic indication, thoracic duct embolization, to other lymphatic disorders (chylous ascites, lymphoceles, liver lymphorrhea, protein-losing enteropathy). The growth of lymphatic research and the standardization of the lymphatic interventions require a multidisciplinary and collaborative approach between physicians and researchers.

Risk factors of chylous ascites and its relationship with long-term prognosis in laparoscopic D3 lymphadenectomy for right colon cancer

BACKGROUND

Chylous ascites (CA) after laparoscopic D3 lymphadenectomy for right colon cancer is not rare. However, the risk factors for CA have not been fully explored. Few studies have investigated the effect of CA on long-term prognosis.

METHODS

The clinical data of patients with right colon cancer who underwent laparoscopic D3 lymphadenectomy in five centers from January 2013 to December 2018 were retrospectively collected. Univariate and multivariate analyses were performed to determine the clinicopathological factors associated with CA. Then, the long-term prognosis of patients with and without CA was compared by propensity score matching and Kaplan-Meier survival analysis.

RESULTS

The incidence of CA was 4.4% (48/1090). Pathological T stage (p = 0.025), dissection along the left side of the superior mesenteric artery (p < 0.001) and the number of retrieved lymph nodes (p < 0.001) were independent risk factors for CA. After propensity score matching, 48 patients in the CA group and 353 patients in the non-CA group were enrolled. Kaplan-Meier survival analysis indicated that CA was not associated with overall survival (p = 0.454) and disease-free survival (p = 0.163). In patients with stage III right colon cancer, there were no significant differences in overall survival (p = 0.501) and disease-free survival (p = 0.254).

CONCLUSIONS

Pathological T stage, number of retrieved lymph nodes, and left side dissection along the superior mesenteric artery were independent risk factors for CA after laparoscopic D3 lymphadenectomy. CA does not impair the oncological outcomes of patients.

OUP accepted manuscript

Post-surgical chylous ascites (CA) is extremely rare in colon surgery, known as the extravasation of creamy fluid rich in triglycerides accumulating in the peritoneal cavity. The incidence of CA after colorectal surgery remains between 1 and 6.5%. A 71-year-old female presented to the Emergency Department complaining of generalized abdominal pain, weakness and anorexia for several days ago and episodes of hematochezia which started the day before admission. Biopsy from colonoscopy revealed mucinous adenocarcinoma. Rectal mass resection with Hartmann’s procedure was performed due to obstructive recto-colonic mass. Pathology report confirmed pT4aN0M0 tumor invading through the visceral peritoneum. On post-operative Day number 4, drainage output increased, changing appearance to a whitish color. The diagnosis of CA was confirmed by obtaining >550 mg per dL of triglycerides. Changes to a high-protein, low-fat with medium chain fatty acids were made to her enteral diet. After 48 hours of diet adjustment, the drainage output of CA resolved.