Surgical repair of intractable chylous ascites following laparoscopic anterior resection

Chylous ascites is the accumulation of a milk-like peritoneal fluid rich in triglycerides and it is an unusual complication following surgical treatment of colorectal cancer. Conservative management is usually sufficientin patients with chylous ascites after surgery. However,we describe a patient with intractable chylous ascites after laparoscopic anterior resection for sigmoid colon cancer who failed initial conservative treatment. This patient was successfully managed by surgery.

Chylous ascites in colorectal surgery:A systematic review

BACKGROUND Chylous ascites is a rare complication in colorectal surgery with limited evidence.AIM To systematically review all available evidence to describe the incidence,clinical presentation,risk factors and management strategies.METHODS The systematic review was performed through PubMed,MEDLINE,EMBASE and Cochrane and cross-checked up to November 2020.The data collated included:Demographics,indications(benign vs malignant),site of disease,surgical approach,extent of lymphadenectomy,day to and method of diagnosis of chylous ascites and management strategies.RESULTS A total of 28 studies were included in the final analysis(426 cases).Patient age ranged from 31 to 89 years.All except one case were performed for malignancy.Of the 426 cases,195 were right-colonic,121 left-colonic,103 pelvic surgeries and 7 others.The majority were diagnosed during the same inpatient stay by recognition of typical drain appearance and increased volume.Three cases were diagnosed during outpatient visits with increased abdominal distention and subsequently underwent paracentesis.Most cases were managed successfully non-operatively(fasting with prolonged drainage,total parenteral nutrition,somatostatin analogues or a combination of these).Only three cases required surgical intervention after failing conservative management and subsequently resolved completely.Risk factors identified include:Right-colonic surgery/tumour location,extent of lymphadenectomy and number of lymph nodes harvested.CONCLUSION Chylous ascites after colorectal surgery is a relatively rare complication.Whilst the majority of cases resolved without surgical intervention,preventative measures should be undertaken such as meticulous dissection and clipping of lymphatics during lymphadenectomy to prevent morbidity.

Purifying chylous plasma by precluding triglyceride via carboxylated polyethersulfone microfiltration membrane

Precluding the excessive lipoproteins from plasma rapidly and effectively is highly needed for biomedical detection and reducing plasma product scrap in blood donation stations.The current centrifugation procedure is high-cost and time-consuming.Herein,we fabricated an anionic microfiltration polyethersulfone(PES)membrane modified by interface swelling and implanting of acrylic acid(AA)for screening out large particle lipoprotein chylomicron(CM)and adsorbing cationic very low-density lipoproteins(VLDL).To improve the separation efficiency,a two-stage filtration through carboxylated polyethersulfone microfiltration membranes with the mean pore size of 0.45 and 0.22μm respectively were conducted.Attenuated total reflection Fourier transform infrared technique(ATR-FTIR),water contact angle(WCA),Zeta potential and scanning electron microscope(SEM)were employed to characterize the modified membrane.To test the effectiveness of this membrane,plasma flux and concentration variation of plasma components were examined to study the purification effectiveness.Furthermore,the hemocompatibility of modified membranes was tested to confirm its practicability on bloodcontacting materials.The carboxylated polyethersulfone microfiltration membrane shows its promising potential application to purify chylous plasma.

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.

Impact of Chylous Ascites on Colon Cancer in Laparoscopic Surgery

Objectives: To investigate the epidemiology and risk factors of chylous ascites. Methods: We identified the cases of 913 consecutive patients who underwenturgery for colorectal cancerat our University Hospital between January 2005and December2016. We divided the patients into thosewith and those without chylous ascites and compared the two groups by age, gender, body mass index, tumor location, T, N factor, stage, operation time, intra-operative bleeding, and duration of postoperative hospital stay. Results: Chylous ascites developed in 8 of the 913 patients (0.8%). Neither age, sex, tumor location, and body mass indexnor number of lymph nodeswereassociated with postoperative chylous ascites. Ascites occurred significantly less frequently in the early stage of colorectal cancer than in the late stage (p = 0.04). There was no significant difference between the groups in operative factors, including operation time and blood loss. Postoperative hospital stays were longer in patients with chylous ascites (20.5 days) than in those without (11 days) (p = 0.02). Conclusions: Late stage was one of the risk factors for chylous ascites in the present study. Other risks, such as tumor location and blood loss,will vary from institution to institution.

Non chylous filarial ascites: A rare case report

Filariasis is a common health problem in tropical and subtropical regions including India. It commonly presents with lymphatic involvement in form of nonpitting pedal edema, chylous ascites, chyluria,hydrocele and lymphocele. Detection of microfilaria in ascitic fluid is an extremely uncommon finding. We present a case of non chylous ascites where microfilaria were detected in the ascitic fluid.

Chylous ascites in laparoscopic renal surgery: Where do we stand?

Postoperative chylous ascites, which is caused by the disruption of lymphatic channels and persistent lymphatic leakage, was a rare complication in the urologic field before laparoscopic surgery was introduced. Now that laparoscopic urologic surgery, especially laparoscopic nephrectomy, is widely performed, chylous ascites as a complication of laparoscopic renal surgery has been reported more frequently. With these accumulated experiences and data comes knowledge about the proper diagnosis and management of chylous ascites, although there is still some debate regarding the correct protocol for diagnosis and management. Therefore, we performed a systematic review of the current literature regarding the etiology, incidence, diagnosis, management, and prognosis of chylous ascites after laparoscopic renal surgery, as well as strategies used to prevent it, and discuss current perspectives on overcoming this complication in the laparoscopic age.

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.

Chylous pleural effusion caused by mediastinal angiomyolipomas

Classical angiomyolipomas are benign tumors composed of various tissues, including fat, abnormal blood vessels and smooth muscle cells. The present study reports a male patient affected by mediastinal angiomyolipomas with massive chylous pleural effusion. The tumors were characterized with histological and immunohistochemical methods.

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.

Changes over time in milk test results following pancreatectomy

AIM: To investigate changes over time in, and effects of sealing technology on, milk test results following pancreatectomy. METHODS: From April 2008 to October 2013, 66 pancreatic resections were performed at the Iwakuni Clinical Center. The milk test has been routinely conducted at the institute whenever possible during pancreatectomy. The milk test comprises the following procedure: A nasogastric tube is inserted until the third portion of the duodenum, followed by injection of 100 mL of milk through the tube. If a chyle leak is present, the patient tests positive in this milk test based on the observation of a white milky discharge. Positive milk test rates, leakage sites, and chylous ascites incidence were examined. Liga Sure?(LS; Covidien, Dublin, Ireland), a vessel-sealing device, is routinely used in pancreatectomy. Positive milk test rates before and after use of LS, as well as drain discharge volume at the 2^(nd) and 3^(rd) postoperative days, were compared retrospectively. Finally, positive milk test rates and chylous ascites incidence were compared with the results of a previous report.RESULTS: Fifty-nine milk tests were conducted during pancreatectomy. The positive milk test rate for all pancreatectomy cases was 13.6%(8 of 59 cases). One case developed postoperative chylous ascites(2.1% among the pancreatoduedenectomy cases and 1.7% among all pancreatectomies). Positive rates by procedure were 12.8% for pancreatoduodenectomy and 22.2% for distal pancreatectomy. Positive rates by disease were 17.9% for pancreatic and 5.9% for biliary diseases. When comparing results from before and after use of LS, positive milk test rates in pancreatoduodenectomy were 13.0% before and 12.5% after, while those in distal pancreatectomy were 33.3% and 0%. Drainage volume tended to decrease when LS was used on the 3^(rd) postoperative day(volumes were 424 ± 303 mL before LS and 285 ± 185 mL after, P = 0.056). Both chylous ascites incidence and positive milk test rates decreased slightly compared with those rates from the previous study. CONCLUSION: Positive milk test rates and chylous ascites incidence decreased over time. Sealing technology may thus play an important role in preventing postoperative chylous ascites.

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.

Chylorrhea complicating D2＋a gastrectomy： review of the literature and clarification of terminology apropos one case

Lymphatic complications leading to retention,accumulation or drainage of peritoneal fluid are frequently encountered following extended or superextended lymphadenectomy for gastric cancer.1 The vast majority of these drainages usually subsides spontaneously, but in some instances they can persist for long period of time causing significant morbidity.However, the classification,