Colon signet-ring cell carcinoma with chylous ascites caused by immunosuppressants following liver transplantation:A case report

BACKGROUND Chylous ascites is caused by disruption of the lymphatic system,which is characterized by the accumulation of a turbid fluid containing high levels of triglycerides within the abdominal cavity.The two most common causes are cirrhosis and tuberculosis,and colon signer ring cell carcinoma(SRCC)due to the use of immunosuppressants is extremely rare in cirrhotic patients after liver transplantation,making it prone to misdiagnosis and missed diagnosis.CASE SUMMARY A 52-year-old man who underwent liver transplantation and was administered with immunosuppressants for 8 months was admitted with a 3-month history of progressive abdominal distention.Initially,based on lymphoscintigraphy and lymphangiography,lymphatic obstruction was considered,and cystellar chyli decompression with band lysis and external membrane stripping of the lymphatic duct was performed.However,his abdominal distention was persistent without resolution.Abdominal paracentesis revealed allogenic cells in the ascites,and immunohistochemistry analysis revealed adenocarcinoma cells with phenotypic features suggestive of a gastrointestinal origin.Gastrointestinal endoscopy was performed,and biopsy showed atypical signet ring cells in the ileocecal valve.The patient eventually died after a three-month follow-up due to progression of the tumor.CONCLUSION Colon SRCC,caused by immunosuppressants,is an unusual but un-neglected cause of chylous ascites.

Chylous ascites after pancreatico-duodenectomy

BACKGROUND:Chylous ascites(CA) following pancreatico-duodenectomy(PD) is a rare complication secondary to disruption of the lymphatics during extended retroperitoneal lymph node dissection. The majority of cases do not develop CA,possibly due to patency of the proximal thoracic duct and good collaterals. CA may be due to a consequence of occult obstruction of the proximal thoracic duct by malignant infiltration or tumor embolus. This study was to report the incidence of CA and its outcomes of management. METHODS:A retrospective search of our liver database was performed using the 'pancreatico-duodenectomy','chylous ascites' from January 2000 to December 2005. The medical records of CA patients and their management and outcome were reviewed. RESULTS:In 138 patients who had undergone PD in our centre for pancreatic malignancy,3 were identified with CA and managed by abdominal paracentesis. CA resolved in 2 patients with low fat medium chain triglyceride diet alone and 1 patient had total parenteral nutrition(TPN) for persistent CA. Resolution of CA occurred in these 3 patients at a median follow-up of 4 weeks(range 4-12 weeks). Histologically,resected specimen confirmed pancreatic adenocarcinoma in all the patients. Two patients developed loco-regional recurrences at a median follow up of 8 months(range 6-10 months). And the other was currently disease free at a 10-month follow up. CONCLUSIONS:CA as an uncommon postoperative complication requires frequent paracentesis,prolonged hospital stay,and delayed adjuvant chemotherapy. CA istreated with low fat medium chain triglyceride diet or occasionally TPN is required.

Novel management indications for conservative treatment of chylous ascites after gastric cancer surgery

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 lowfat 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(R~2 = 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.

Nomogram for predicting chylous ascites after right colectomy

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.

A case report of chylous ascites after cardiac surgery

Background:Chylous ascites(CA),an emulsion rich in triglycerides,is a rare type of ascites,especially after cardiac surgery.Also,there are few reports of the occurrence of CA after mitral valve replacement,aortic valve replacement,tricuspid valvuloplasty,and coronary artery bypass grafting.Case presentation:We report the case of a 53-year-old man who underwent surgery for a diagnosis of mitral incompetence,aortic incompetence,tricuspid incompetence,and coronary atherosclerotic heart disease.Fifteen days after surgery,3000 mL of milky-yellow ascites appeared in the abdominal cavity,diagnosed as CA by laboratory examination.The ascites gradually disappeared after being drained,and the patients improved.The curative was objective,but the exact cause is not clear.Conclusion:Although CA is rare,it may occur during the surgical intervention in cardiac surgery.

Successful management of chylous ascites with total parenteral nutrition,somatostatin,and fibrin glue

Chylous ascites, an uncommon disease usually caused by obstruction or rupture of the peritoneal or retroperitoneal lymphatic glands, is defined as the accumulation of chyle in the peritoneal cavity. It is a difficult management problem due to the serious mechanical, nutritional, and immunological consequences of the constant loss of protein and lymphocytes. Most investigators believe that the incidence of chylous ascites is increasing because of more aggressive thoracic and retroperitoneal surgery and also because of the prolonged survival of patients with cancer. Although the incidence of chylous ascites has increased in recent years, treatment remains unsatisfactory. The standard conservative treatments include paracentesis, a medium chain triglyceride （MCT） based diet, total parenteral nutrition （TPN）, and recently recommended somatostatin, are preferable in most cases, but usually need several weeks to cure chyloperitonum. Open or laparoscopic ligation of ruptured lymph ducts, a commonly used procedure for persistent chylous ascites, may fail in patients without visible chylous leak. Fibrin glue, a widely used approach to treat various kinds of fistulae, has recently been reported to seal chylous leak during operation. Here we present two cases of chylous ascites who were successfully treated with fibrin glue in different settings.

Chylous Ascites:A Review of Pathogenesis,Diagnosis and Treatment

Chylous ascites(CA)is a rare form of ascites that results from the leakage of lipid-rich lymph into the peritoneal cavity.This usually occurs due to trauma and rupture of the lymphatics or increased peritoneal lymphatic pressure secondary to obstruction.The underlying etiologies for CA have been classified as traumatic,congenital,infectious,neoplastic,postoperative,cirrhotic or cardiogenic.Since malignancy and cirrhosis account for about two-thirds of all the cases of CA in Western countries,in this article we have attempted to reclassify CA based on portal and non-portal etiologies.The diagnosis of CA is based on the distinct characteristic of the ascitic fluid which includes a milky appearance and a triglyceride level of>200 mg/dL.The management consists of identifying and treating the underlying disease process,dietary modification,and diuretics.Some studies have also supported the use of agents such as orlistat,somatostatin,octreotide and etilefrine.Paracentesis and surgical interventions in the form of transjugular intrahepatic portosystemic shunt(commonly known as TIPS),peritoneal shunt,angiography with embolization of a leaking vessel,and laparotomy remain as treatment options for cases refractory to medical management.

Chylous ascites has a higher incidence after robotic surgery and is associated with poor recurrence-free survival after rectal cancer surgery

Background:Postoperative chylous ascites is an infrequent condition after colorectal surgery and is easily treatable.However,its effect on the long-term oncological prognosis is not well established.This study aimed to investigate the short-term and long-term impact of chylous ascites treated with neoadjuvant therapy followed by rectal cancer surgery and to evaluate the incidence of chylous ascites after different surgical approaches.Methods:A total of 898 locally advanced rectal cancer patients treated with neoadjuvant chemoradiotherapy followed by surgery between January 2010 and December 2018 were included.The clinicopathological data and outcomes of the patients with chylous ascites were compared with those of the patients without chylous ascites.The primary endpoint was recurrence-free survival(RFS).To balance baseline confounders between groups,propensity score matching(PSM)was performed for each patient with a logistic regression model.Results:Chylous ascites was detected in 3.8%(34/898)of the patients.The incidence of chylous ascites was highest after robotic surgery(6.9%,6/86),followed by laparoscopic surgery(4.2%,26/618)and open surgery(1.0%,2/192,P=0.021).The patients with chylous ascites had a significantly higher number of lymph nodes harvested(15.6 vs.12.8,P=0.009)and a 3-day longer postoperative hospital stay(P=0.017).The 5-year RFS rate was 64.5%in the chylous ascites group,which was significantly lower than the rate in the no chylous ascites group(79.9%;P=0.007).The results remained unchanged after PSM was performed.The chylous ascites group showed a nonsignificant trend towards a higher peritoneal metastasis risk(5.9%vs.1.6%,P=0.120).Univariate analysis and multivariate analysis confirmed chylous ascites(hazard ratio=3.038,P<0.001)as an independent negative prognostic factor for RFS.Conclusions:Considering the higher incidence of chylous ascites after laparoscopic and robotic surgery and its adverse prognosis,we recommend sufficient coagulation of the lymphatic tissue near the vessel origins,especially during minimally invasive surgery.

Prevalence and risk factors of lymphatic dysfunction in cirrhosis patients with refractory ascites:An often unconsidered mechanism

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.

Lymphatic dysfunction in advanced cirrhosis:Contextual perspective and clinical implications

The lymphatic system plays a very important role in body fluid homeostasis,adaptive immunity,and the transportation of lipid and waste products.In patients with liver cirrhosis,capillary filtration markedly increases,primarily due to a rise in hydrostatic pressure,leading to enhanced production of lymph.Initially,lymphatic vasculature expansion helps to prevent fluid from accumulating by returning it back to the systemic circulation.However,the lymphatic functions become compromised with the progression of cirrhosis and,consequently,the lymphatic compensatory mechanism gets overwhelmed,contributing to the development and eventual worsening of ascites and edema.Neurohormonal changes,low-grade chronic inflammation,and compounding effects of predisposing factors such as old age,obesity,and metabolic syndrome appear to play a significant role in the lymphatic dysfunction of cirrhosis.Sustained portal hypertension can contribute to the development of intestinal lymphangiectasia,which may rupture into the intestinal lumen,resulting in the loss of protein,chylomicrons,and lymphocyte,with many clinical consequences.Rarely,due to high pressure,the rupture of the subserosal lymphatics into the abdomen results in the formation of chylous ascites.Despite being highly significant,lymphatic dysfunctions in cirrhosis have largely been ignored;its mechanistic pathogenesis and clinical implications have not been studied in depth.No recommendation exists for the diagnostic evaluation and therapeutic strategies,with respect to lymphatic dysfunction in patients with cirrhosis.This article discusses the perspectives and clinical implications,and provides insights into the management strategies for lymphatic dysfunction in patients with cirrhosis.