A case of successful conservative treatment for chylous ascites after living-donor liver transplantation

Spontaneous Chylous Ascites After Liver Transplantation Secondary to Everolimus: A Case Report

Chylous ascites (CA) is an uncommon entity with several etiologies. Only a few cases of CA have been reported as a complication after liver transplantation (LT). Most of these cases occurred within 1 month after surgery and typically resulted from traumatic intraoperative injury leading to disruption of lymphatics. Although peripheral lymphedema has been frequently correlated with use of calcineurin inhibitors, associated spontaneous CA has only been reported in a few cases after renal transplantation. We report a case of delayed spontaneous CA after LT caused by the use of the mammalian target of rapamycin (mTOR) inhibitor everolimus. Everolimus was introduced in our patient early after transplantation because of tacrolimus-induced microangiopathy, and years later the patient presented with spontaneous CA. After excluding other causes of CA, everolimus was discontinued, and immunosuppression was maintained by increasing prednisone and continuing mycophenolate mofetil. Additionally, the patient was treated with percutaneous drain placement and began a low-fat, high-protein diet. One month later the patient had complete resolution of symptoms with no recurrence of ascites. To our knowledge, this is the first case of delayed-onset CA caused by everolimus after LT.

Management of chylous ascites following pancreaticobiliary surgery

Background

Chyle leak is an uncommon form of ascites occurring due to the accumulation of lipid‐rich lymph into the peritoneal cavity. Traumatic injury to the lymphatic system due to pancreaticobiliary surgery can lead to this phenomenon.

Method

We retrospectively evaluated the data of 159 patients of pancreticobiliary surgery from January 2012 to December 2016. Five patients (5/137, 3.6%) sustained a chylous leak following pancreaticoduodenectomy and one patient (1/22, 4.5%) sustained a chylous leak following Roux‐en‐Y hepaticojejunostomy for postcholecystectomy biliary stricture.

Results

Average daily output was 441 mL (range: 150–800 mL/day), and total duration of output was 16.5 days (range: 4–35 days). Mean hospital stay increased to 19.1 days (range: 10–40 days). All the patients were successfully managed conservatively with a combination of customized enteral feeds, supplemental parenteral nutrition, and octreotide. One patient required additional percutaneous drainage.

Conclusion

Chyle leak can be successfully treated with conservative management but at the cost of increased hospital stay.

Delayed-Onset Chylous Ascites After a Living-Donor Liver Transplant: First Case Successfully Treated With Conservative Treatment?

Chylous ascites is a rare complication in liver transplant. Few cases have been reported to date. In most cases, chylous ascites is diagnosed within 1 month after surgery because of intraoperative injury of the hilar lymphatic system. Preoperative massive ascites and use of a LigaSure vessel sealing system for hilar dissection have been reported as risk factors. We report a case of chylous ascites after a living-donor liver transplant that was diagnosed after 6 months of uneventful follow-up. Sirolimus was added to cyclosporine early (2 wk after the operation) owing to poor renal function and it was found to be high (> 22 ng/mL) when the chylous ascites occurred. The patient was treated with total parenteral nutrition in combination with Sandostatin and rapid tapering of sirolimus after the failed initial conservative treatment. Residual abdominal fullness after meals and lymphedema of the legs disappeared 1 month after discontinuing sirolimus. This is the first case of delayed-onset chylous ascites after a liver transplant that was successfully treated conservatively.