Surgical treatment of chylous ascites

Abstracts

Chylous ascites is a rare complication after abdominal procedures and blunt abdominal trauma, associated with high morbidity and difficult management. When clinical treatment fails, surgical intervention is necessary, despite the limited success rate. Two cases are reported: the first patient had a blunt abdominal trauma and the second patient underwent laparoscopic Nissen fundoplication; both developed chylous ascites and required surgical treatment with suture repair of the thoracic duct, close to the diaphragm. There was clinical improvement and ascites was absent at a 24-month follow-up.

Chylous ascites; lymphatic diseases; laparoscopy

A ascite quilosa é uma complicação rara após procedimentos cirúrgicos e trauma abdominal, apresentando elevada morbidade e difícil manejo. Nos casos refratários ao tratamento clínico habitual, o tratamento cirúrgico se impõe, apesar da baixa taxa de sucesso. Dois casos são apresentados: o primeiro paciente foi vítima de trauma abdominal contuso e o segundo foi submetido a hernioplastia hiatal a Nissen videolaparoscópica, ambos evoluindo com ascite quilosa que necessitou de tratamento cirúrgico através da ligadura do ducto torácico, junto aos pilares diafragmáticos. Os pacientes evoluíram com melhora clínica e ausência de ascite após 24 meses de seguimento.

Ascite quilosa; doenças linfáticas; laparoscopia

CASE REPORT

Surgical treatment of chylous ascites

Claudia Stein Gomes^I; Gustavo Ioshio Handa^I; Fabio Porto Silveira^II; Vinicius Zendrini Buzingnani^I; Fernanda Macedo Binati^I; Elizana Stella Lopes Rasera^I

^IServiço de Angiologia e Cirurgia Vascular, Santa Casa de Misericórdia de Curitiba, Curitiba, PR, Brazil

^IIServiço de Cirurgia Geral, Santa Casa de Misericórdia de Curitiba, Curitiba, PR, Brazil

Correspondence

ABSTRACT

Chylous ascites is a rare complication after abdominal procedures and blunt abdominal trauma, associated with high morbidity and difficult management. When clinical treatment fails, surgical intervention is necessary, despite the limited success rate. Two cases are reported: the first patient had a blunt abdominal trauma and the second patient underwent laparoscopic Nissen fundoplication; both developed chylous ascites and required surgical treatment with suture ligation of the thoracic duct, at the level of the crura of the diaphragm. There was clinical improvement and ascites was absent at a 24-month follow-up.

Keywords: Chylous ascites, lymphatic disease, laparoscopy.

Introduction

Chylous ascites is a rare complication after abdominal procedures and blunt chest and abdominal trauma. Clinical treatment based on a high-protein low-fat diet, parenteral nutrition, and somatostatin or octreotide administration has been the initial treatment of choice. However, in patients whose ascites is refractory to these therapeutic options, surgical intervention is necessary, despite the lack of consensus in the literature about the best surgical approach and moment to perform it. We reported the cases of two patients with postsurgical, posttraumatic chylous ascites who underwent successful surgical treatment with sclerosing agents and suture ligation of the thoracic duct at the level of the crura of the diaphragm.

Case report

Case 1

A 36-year-old female patient, injured in auto-to-fixed object collision, presented with blunt chest and abdominal trauma, receiving care at the city hospital emergency room, complaining of chest pain and mild dyspnea. Chest radiography did not detect abnormalities, and the patient was discharged. Six months after the accident, the patient complained of dyspnea and suprapubic pain, and pelvic ultrasound revealed fluid at the bottom of the pouch of Douglas, being then investigated by colonoscopy and upper digestive endoscopy, without significant abnormalities that could justify a diagnosis of ascites. Chest radiography revealed bilateral pleural effusion, and the patient was submitted to thoracentesis which revealed a milky fluid. The patient was referred to a major medical service, where she was vastly investigated to discard neoplastic causes (liver biopsy, bone marrow biopsy, chest and abdominal computed axial tomography). All findings were negative for malignancy, confirming the diagnosis of ascites and chylous pleural effusion secondary to trauma. Due to the difficulty to control fistula output (> 1,000 mL/day), the patient was started on total parenteral nutrition associated with chemical pleurodesis to the right. The patient progressed with catheter sepsis related to infection in the central venous line and respiratory distress syndrome, being sent to the intensive care unit (ICU), where she stayed for 2 months. After improvement of clinical symptoms and output control, a restricted oral diet was reintroduced with parenteral nutrition supplementation, but ascites relapsed. Lymphography (Figure 1) and lymphoscintigraphy (Figure 2) were performed, without visualization of the thoracic duct. The patient was fasted again and given total parenteral nutrition, being started on somatostatin. The patient progressed with ascites improvement and was gradually restarted on a restricted oral diet until total parenteral nutrition withdrawal, with apparent case resolution and hospital discharge.

After 1 week, the patient returned with large-volume ascites and abdominal pain, chylous fluid drainage (triglycerides > 1,000 mg/dL) being performed, with no evidence of infection (negative cultures). The patient was then referred to the hospital Santa Casa de Misericórdia, in the city of Curitiba, southern Brazil. After clinical stabilization and complementary diagnostic investigation by chest and abdominal tomography (Figures 3 and 4), the patient underwent explorative laparotomy, with aspiration of 6 L of chylous ascitic fluid, with access to the crura of the diaphragm and ligation of the lymphatic collectors at this level, with drainage of the abdominal cavity using a tubular drain. The patient showed good postoperative outcome, with no lymph secretion drainage, and hospital discharge occurred on the 10th postoperative day. The patient is currently in the 24th postoperative month, with normal nutritional status and no evidence of ascites in the examinations (chest radiography and abdominal ultrasound) performed at 6-month intervals.

Case 2

A 50-year-old female patient, with gastroesophageal reflux disease, presented with large hiatal hernia and underwent laparoscopic Nissen fundoplication and reduction of the stomach within the abdominal cavity. The patient showed good postoperative outcome, and hospital discharge occurred on the first postoperative day.

Thirty days after the surgical procedure, the patient presented with pain in right hemithorax and mild dyspnea, in addition to increase in abdominal volume. Chest radiography revealed large pleural effusion to the right, and total abdominal ultrasound showed free fluid in the peritoneal cavity. Thoracentesis showed chylothorax. The patient underwent right-sided thoracotomy and ligation of the thoracic duct at the thoracoabdominal junction and aspiration of mediastinal chylous ascites, with drainage of about 4 L of fluid.

During the postoperative period, the patient progressed with chylous ascites relapse, being submitted to another laparoscopy for surgical abdominal ligation of lymphatic vessels. During the surgical procedure, 2 L of chylous ascitic fluid were aspirated, and a new dissection was performed at the level of the crura of the diaphragm, with no leak detection. Mineral oil was administered by nasogastric tube, with detection of lymph leak close to the crura of the diaphragm. After local dissection, it was not possible to identify the duct, and a sclerotherapy of the periaortic lymphatic vessels was performed with 50% glucose, ceasing lymph secretion drainage. The abdominal cavity was drained with a Blake drain placed next to the crus of the diaphragm.

The patient was maintained on total parenteral nutrition for 10 days, with no drainage of the chylous secretion through the drain. The patient was then started on a fat-free diet, containing only medium-chain triglycerides. Twenty days after surgical intervention, the patient progressed without chylous secretion through the drain, with removal of the drain and resumption of a non-restricted diet.

Total abdominal ultrasound was performed 30, 60, and 90 days after surgery, with no evidence of ascites. There was clinical improvement and the patient is currently in the 23rd postoperative month.

Discussion

Chylous ascites is a peritoneal milky fluid with high triglyceride content, with an estimated incidence of 1 case per 20,000 admissions to a large university-based hospital.¹ There are 3 mechanisms described for the development of chylous ascites:² obstruction to lymphatic flow by malignant neoplasms that cause subserous leaky lymphatics dilated into the peritoneal cavity; lymph exuded from dilated retroperitoneal vessel walls allowed to drain through a fistula into the peritoneal space (congenital lymphangiectasia); and traumatic or iatrogenic obstruction to the thoracic duct causing direct leakage of chyle through a lymphoperitoneal fistula.

The main causes of ascites in western countries are malignant neoplasms and biliary cirrhosis; in developing countries, however, tuberculosis and filariosis are the leading causes. Other causes have been described, including the following: congenital, inflammatory, postsurgical, traumatic, and miscellaneous causes. Postsurgical and posttraumatic chylous ascites may occur early (around 1 week) due to lymphatic vessel injury, or late (within weeks or months) due to lymphatic vessel adherence or external compression.³ Surgical interventions that might result in chylous ascites include abdominal aortic aneurysm repair, retroperitoneal lymph node dissection, laparoscopic Nissen fundoplication,⁴ peritoneal dialysis catheter implantation, distal splenorenal shunt, laparoscopic live donor nephrectomy, and liver transplantation. Postsurgical chylous ascites generally results from a fistula between the chyle cistern or intestinal lymphatics and the peritoneal cavity, representing a significant complication with serious metabolic, nutritional and immunologic implications.

Chylothorax, present in the above reported cases, originates from trauma in 50% of cases, and may be caused by thoracic duct injuries above the diaphragm or by intra-abdominal injuries of the duct with secretion of chyle into the pleural cavity. The most associated surgical procedures include esophagectomy and surgical treatment for congenital cardiopathy, but chylothorax may occur after a number of abdominal and cervical procedures, ⁵ interfering with the definition of the location of duct injury, as in the cases herein reported.

Clinical manifestations include weight loss, dyspnea, nonspecific abdominal pain, malnutrition, nausea, early saciety, fever, night sweats.^2,6 Paracentesis is the main diagnostic tool, typically a cloudy fluid is obtained with fluid triglyceride levels above 110 mg/dL.^1,7 Abdominal ultrasound and computed tomography assist in the diagnosis, since they show fluid collection in the abdomen and guide paracentesis. Lymphoscintigraphy is a useful tool in the identification of lymph drainage location and may guide surgical intervention.⁸

Clinical treatment consists of a high-protein low-fat diet, total parenteral nutrition, and somatostatin or octreotide administration. Long-chain triglyceride dietary restriction prevents the conversion of triglycerides into monoglycerides and free fatty acids, which are transported as chylomicrons into the intestinal lymph ducts. Thus, a low-fat diet with medium-chain triglyceride supplementation reduces chyle production and flow. A total parenteral nutrition is the next treatment step, since it rapidly reduces lymph flow and shows success rates greater than 50%.^9,10 Somatostatin and octreotide inhibit lymph secretion through specific receptors located in the intestinal lymphatic vessel walls.^11-13 In patients with large-volume ascites, relief paracentesis should be performed and repeated when necessary to relieve abdominal discomfort and dyspnea.

Surgical treatment has proved beneficial in cases of postsurgical, neoplastic or congenital chylous ascites, lymphography and lymphoscintigraphy being recommended prior to the surgical procedure in an attempt to identify the anatomic leak location. However, due to the difficulty to access the location of fistula and due to adherence often found in reoperation, surgical success is limited. Some anatomic variations may also hinder surgical approach: low-level thoracic duct (L1-L2), accessible through the section of the crus. However, it often begins at level T11-T12, impeding abdominal access, which may lead to treatment failure. Thoracic duct is the access pathway most used in the treatment of primary reflux or high obstructions, usually tumors, and may be used in order perform suture ligation in chylous ascites. The identification of leak location during the surgical procedure may be facilitated by preoperative consumption of high-fat foods or preoperative mineral oil or patent blue by nasogastric tube, but this goal is not always achieved.

Jensen & Weiss¹⁴ reported a case of chylous ascites after laparoscopic cholecystectomy, in which suture ligation and fibrin glue were used to close chylous leaks in the hepatic bed of the gallbladder.

There are several cases in the literature of chylous ascites after abdominal aortic aneurysm repair, with a mortality rate of 11 to 18%. Leibovich et al.,³ in a review of 102 cases of chylous ascites, found 81% of these associated with abdominal aortic repair. Busch et al.¹⁵ performed multiple ligations of the lymphatic vessels close to the anastomosis between the aorta and the prosthesis followed by omentoplasty. The patient, however, showed chylous secretion drainage, and only after total parenteral nutrition and dietary control for 2 months there was chylous ascites resolution. Peritoneovenous shunt was described by LeVeen et al.,¹⁶ who successfully trated 9 out of 10 cases of chylous ascites, a procedure repeated by Sarazin & Sauter¹⁷ and Fleisher et al.¹⁸ in the treatment of chylous ascites after abdominal aortic aneurysm repair. However, Press & Kaufman¹⁹ performed this procedure in four patients, and all cases showed shunt occlusion. This procedure is no longer used due to a high incidence of complications, such as disseminated intravascular coagulation in sepsis, electrolytic disorders, pulmonary embolism, intestinal occlusion, and shunt occlusion, due to increased lymph viscosity.^20,21

Laparoscopic procedures have demonstrated advances in the treatment of chylous ascites, by confirming diagnosis, performing ascites drainage, and in the search and treatment of the location of chylous drainage in the abdomen or retroperitoneum. The treatment includes ressection of lymphoid dysplastic tissues, ligation of incompetent lymphatic vessels, dilated lymphatic vessels or lymphovenous microsurgical shunts treated with carbon dioxide laser.^19-23 In the second case reported, laparoscopic sclerotherapy of the lymphatic vessels close to the crura of the diaphragm was a successful intervention.

Posttraumatic chyloperitoneum is a rare injury, with approximately 16 cases reported after blunt trauma, more than half in children.^23,24 There are five case reports of isolated bile duct injury. In general, bile duct injury is followed by injuries in other organs, such as liver, duodenum, kidney, and pancreas. Clinical presentation of chyloperitoneum is often nonspecific, but abdominal computed tomography may reveal fluid collection with fat-fluid level, pathognomonic of this condition. Immediate traumatic injury intervention should consist of plain ligation of the lymph duct, with the use of fibrin glue as a sealant, as described in the literature.²⁵ There is no evidence supporting the need for additional postoperative measures such as parenteral nutrition or octreotide.²³ The management of traumatic chronic chylous ascites follows the same principles applied to postsurgical chylous ascites.

The first case reported refers to posttraumatic chylous ascites, a clinical entity of difficult diagnosis, investigation and management, which often requires several diagnostic and therapeutic tools to elucidade and resolve the case. Ligation of the lymphatic vessels close to the crura of the diaphragm is a difficult technique to be performed, not always yielding successful results as the ones herein reported.

Conclusion

The management of chylous ascites remains a therapeutic challenge, with high morbidity rates among patients and a challenge for those who treat these patients. Initial treatment should consist of dietary measures and parenteral nutrition, surgical treatment being performed in refractory cases. Open-surgery or laparoscopic ligation of the lymphatic vessels should be considered as surgical options, which might prove effective in pre-selected cases.

References

• 1. Cárdenas A, Chopra S. Chylous ascites. Am J Gastroenterol. 2002;97:1896-9000.
• 2. Browse NL, Wilson NM, Russo F, Al-Hassan H, Allen DR. Aetiology and treatment of chylous ascites. Br J Surg. 1992;79:1145-50.
• 3. Leibovich I, Mor Y, Golomb J, Ramon J. The diagnosis and management of postoperative chylous ascites. J Urol. 2002;167:449-57.
• 4. Bacelar TS, de Albuquerque AC, de Arruda PC, Ferraz AA, Ferraz EM. Postoperative chylous ascites: a rare complication of laparoscopic Nissen fundoplication. JSLS. 2003;7:269-71.
• 5. Doerr CH, Allen MS, Nichols FC 3rd, Ryu JH. Etiology of chylothorax in 203 patients. Mayo Clin Proc. 2005;80:867-70.
• 6. Aalami OO, Allen DB, Organ CH Jr. Chylous ascites: a collective review. Surgery. 2000;128:761-78.
• 7. Runyon BA, Hoefs JC, Morgan TR. Ascitic fluid analysis in malignancy-related ascites. Hepatology. 1988;8:1104-9.
• 8. Pui MH, Yueh TC. Lymphoscintigraphy in chyluria, chyloperitoneum and chylothorax. J Nuc Med. 1998;39:1292-6.
• 9. Lee YY, Soong WJ, Lee YS, Hwang B. Total parenteral nutrition as a primary therapeutic modality for congenital chylous ascites: report of one case. Acta Paediatr Taiwan. 2002;43:214-6.
• 10. Alliët P, Young C, Lebenthal E. Chylous ascites: total parenteral nutrition as primary therapeutic modality. Eur J Pediatr. 1992;151:213-4.
• 11. Leong, RW, House, AK, Jeffrey, GP. Chylous ascites caused by portal vein thrombosis treated with octreotide. J Gastroenterol Hepatol. 2003;18:1211
• 12. Mincher L, Evans J, Jenner MW, Varney VA. The successful treatment of chylous effusions in malignant disease with octreotide. Clin Oncol (R Coll Radiol). 2005;17:118-21.
• 13. Huang Q, Jiang ZW, Jiang J, Li N, Li JS. Chylous ascites: treated with total parenteral nutrition and somatostatin. World J Gastroenterol. 2004;10:2588-91.
• 14. Jensen EH, Weiss CA 3rd. Management of chylous ascites after laparoscopic cholecystectomy using minimally invasive techniques: a case report and literature review. Am Surg. 2006;72:60-3.
• 15. Busch T, Lotfi S, Sirbu H, Aleksic I, Dalichau H. Chyloperitoneum. A rare complication after abdominal aortic aneurysm repair. J Cardiovasc Surg. 2000;41:617-8.
• 16. LeVeen HH, Wapnick S, Grosberg S, Kinney MJ. Further experience with peritoneo-venous shunt for ascites. Ann Surg. 1976;184:574-81.
• 17. Sarazin WG, Sauter KE. Chylous ascites following resection of a ruptured abdominal aneurysm. Treatment with a peritoneovenous shunt. Arch Surg. 1986;121:246-7.
• 18. Fleisher HL 3rd, Oren JW, Sumner DS. Chylous ascites after abdominal aortic aneurysmectomy: successful management with a peritoneovenous shunt. J Vasc Surg.1987;6:403-7.
• 19. Press OW, Press NO, Kaufman SD. Evaluation and management of chylous ascites. Ann Intern Med. 1982;96:358-64.
• 20. Ablan CJ, Littooy FN, Freeark RJ. Postoperative chylous ascites: diagnosis and treatment. A series report and literature review. Arch Surg. 1990;125:270-3.
• 21. Voros D, Hadziyannis S. Successful management of postoperative chylous ascites with a peritoneojugular shunt. J Hepatol. 1995;22:380.
• 22. Skala J, Witte C, Bruna J, Case T, Finley P. Chyle leakage after blunt trauma. Lymphology. 1992;25:62-8.
• 23. Meinke AH 3rd, Estes NC, Ernst CB. Chylous ascites following abdominal aortic aneurysmectomy. Management with total parenteral hyperalimentation. Ann Surg. 1979;190:631-3.
• 24. Beal AL, Gormley CM, Gordon DL, Ellis CM. Chylous ascites: a manifestation of blunt abdominal trauma in an infant. J Pediatr Surg. 1998;33:650-2.
• 25. Vollman R, Keenan W, Eraklis A. Post traumatic chylous ascites in infancy. N Eng J Med. 1966;275:875-7.

Publication Dates

• Publication in this collection
  02 Oct 2009
• Date of issue
  June 2009

History

• Accepted
  29 Dec 2008
• Received
  02 July 2008