Thoracic duct lymphangioma and chylous ascites in a 24-year-old female

Lymphangiomas are rare and correspond to 0.7% to 4.0% of mediastinal tumors, and isolated mediastinal location occurs in 1% of cases. They are benign tumors that originate from a congenital malformation of the lymphatic vessels and are diagnosed more frequently in children less than 2 years of age. Chylous ascites is a clinical manifestation of thoracic duct lymphangioma and is composed of lymph accumulation caused by dilation of this lymphatic channel. It appears milky in the peritoneal cavity, containing triglyceride levels higher than 200 mg/dl. We report the case of a young patient with chylous ascites and lymphangioma of the thoracic duct, who was conservatively treated with octreotide and a low-fat diet with medium-chain triglycerides.

Chylous ascites has a higher incidence after robotic surgery and is associated with poor recurrence-free survival after rectal cancer surgery / 中华医学杂志(英文版)

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.

Ascitis quilosa o quiloperitoneo, un desafío diagnostico y un reto en el tratamiento conservador para el cirujano general: presentación de un caso y revisión de la literatura / Chilosa ascites or quiloperitoneo, a diagnostic challenge and a challenge in the conservative treatment for the general surgeon: presentation of a case and review of literature

La "Ascitis Quilosa o Quiloperitoneo", es una entidad clínica rara con incidencia baja y de difícil diagnóstico, poco conocida alrededor del mundo sobre todo en la comunidad quirúrgica, misma que fue descrita por primera vez en 1691. El objetivo del presente artículo es exponer un caso de Ascitis Quilosa o Quiloperitoneo, diagnosticado y tratado en el Centro de Especialidades Clínico - Quirúrgicas Jesús Obrero, en un paciente masculino de 36 años; tras la revisión de antecedentes quirúrgicos, sintomatología, semiología, estudios imagenológicos, laboratoriales, y la revisión sistemática de la literatura; se llegó al diagnóstico final. Además se enfocara no solo conocimientos históricos, etiológicos y fisiopatológicos, sino medios diagnósticos y planes terapéuticos estandarizados conservadores, que implica tomar en cuenta en esta patología una vez diagnosticada; siendo esta una manera de acumular experiencia en el adecuado manejo y a su vez aportar a la literatura médica nacional en el levantamiento epidemiológico y casuístico de esta variedad rara y poco frecuente patología abdominal.

The “Chilosa Ascites or Quiloperitoneo”, is a rare clinical entity with low incidence and difficult to diagnose, little known around the world especially in the surgical community, which was first described in 1691. The objective of this article is to expose a case of Chilosa Ascites or Quiloperitoneo, diagnosed and treated at the Center for Clinical Specialties - Surgical Jesus Obrero, in a male patient of 36 years; after reviewing surgical backgrounds, symptomatology, semiology, imaging, laboratorial studies, and systematic review of literature; the final diagnosis was reached. In addition, it will focus not only historical, etiological and pathophysiological knowledge, but also conservative diagnostic means and standardized therapeutic plans, which involves taking into account this pathology once diagnosed; this being a way to accumulate experience in the proper management and in turn contribute to the national medical literature in the epidemiological and casuistic uprising of this rare and rare abdominal pathology variety.

Tratamiento de quilotórax y quiloascitis refractaria en paciente cirrótico. Caso clínico

Chylous Ascites (CA) and chylothorax (CTx) are associated with obstruction, disruption or insufficiency of the lymphatic system. We report a 68-year-old male, with a history of alcoholic cirrhosis, who had recurrent events of CTx and CA. After a complete study, no other etiologies other than portal hypertension were found. Therapy with diuretics, nothing per mouth, parenteral feeding plus octreotide did not relieve symptoms. A transjugular intrahepatic portosystemic shunt (TIPS) was successfully placed and pleural effusion subsided. This case shows that CA and CTx can be caused by portal hypertension and they may subside employing a multimodal management strategy.

Chylous ascites developing after open thoracoabdominal aortic aneurysm repair in a patient with marfan syndrome

Abstract Chylous ascites is the pathologic accumulation of chylous fluid in the peritoneal cavity, caused by lymphomas, metastatic malignancies, and abdominal surgeries, rarely due to surgical trauma of the cisterna chyli or its major branches. A 24-year-old man with history of Marfan syndrome presented to our hospital with abdominal distention, abdominal pain, fluid in the incision region, and weakness. He had underwent an elective open aneurysm repair surgery nine days before for thoracoabdominal aortic aneurysm. Computed tomography revealed massive fluid collection in the abdominal cavity, which was drained surgically. He was diagnosed with chylous ascites and was discharged after conservative treatment.

Ascitis quilosa en el posoperatorio de hepatectomía derecha / Chylous ascites after right liver resection

La ascitis quilosa posoperatoria (AQP) se debe a acumulación de líquido rico en triglicéridos en la cavidad peritoneal tras una lesión en la cisterna del quilo o en sus afluentes. Es infrecuente verla después de una hepatectomía. Se presenta el caso de un varón de 44 años con adenocarcinoma a 16 cm del margen anal T3N1, con metástasis que ocupaba casi la totalidad del lóbulo hepático derecho. Luego de quimioterapia se realizó hepatectomía derecha, observándose al cuarto día postoperatorio líquido del drenaje endotorácico de aspecto lechoso, con triglicéridos 223 mg/dL y 77 mg/dL de triglicéridos séricos. Se inició dieta sin grasas, hiperproteica, con ácidos grasos de cadena media y octreótide (100 microgramos subcutáneos cada 8 horas), con resolución del cuadro. En conclusión, la complicación quilosa puede tratarse exitosamente con un abordaje menos agresivo, sin suprimir la ingesta oral, utilizando octreótide subcutáneo, dieta exenta de grasas, suplementada con proteínas y ácidos grasos de cadena media.

Postoperative chylous ascites is an intraperitoneal collection of lymphatic fluid enriched with long-chain triglycerides that results from injury of the cisterna chyli or its main tributaries. This complication is rare after liver resections. Here, we report on the case of a 44 year-old man with a T3N1 rectal adenocarcinoma 16 cm above the anal margin, with metastatic compromise of almost the entire right liver lobe. Following chemotherapy, he underwent right liver resection. On postoperative day four, the thoracic drain evidenced milky fluid containing triglyceride 223 mg/dL with serum triglycerides 77 mg/dL. A fat-free diet was indicated with fat-free protein supplements, medium chain triglycerides and octreotide (100 μg subcutaneously every 8 hours), with complete resolution. In conclusion, postoperative chylous complications may be treated successfully by a less aggressive approach, with oral diet, subcutaneous octreotide, fat-free diet supplemented with proteins and medium chain fatty acids.

Quiloperitoneo espontáneo en el embarazo / Spontaneous chyloperitoneum in pregnancy

Introducción. El quiloperitoneo consiste en la presencia de fluido linfático en la cavidad intraabdominal, complicación poco descrita en el embarazo y cuyas repercusiones no están bien establecidas.Reporte de caso. Se presenta el caso de una mujer gestante con embarazo de 36,5 semanas, sin comorbilidades, hospitalizada por presentar cifras tensionales elevadas asociadas a síntomas de encefalopatía hipertensiva y bradicardia fetal sostenida; se le practicó una cesárea urgente en la cual se evidenció corioperitoneo incidental. La tomografía computarizada abdominal de control no demostró alteraciones.Discusión. Se descartaron las principales causas del quiloperitoneo, las cuales son neoplasia maligna y trauma. Se consideró que se trataba de un quiloperitoneo espontáneo posiblemente relacionado con la congestión pélvica propia del embarazo, por vasodilatación secundaria al influjo hormonal, aumento de la presión intraabdominal y contribución del volumen ascítico por la preeclampsia, que genera ruptura traumática de los vasos linfáticos.Conclusión. La ascitis quilosa es una entidad poco frecuente que puede verse asociada con el embarazo. Es fundamental el criterio acertado del ginecoobstetra para determinar tempranamente la etiología

Introduction: Chyloperitoneum consists of the presence of a lymphatic fluid in the intra-abdominal cavity, a complication little described during pregnancy, and whose repercussions are not well established.Case report: A pregnant woman with a pregnancy of 36.5 weeks, without comorbidities, is hospitalized in the context of high blood pressure levels associated with symptoms of hypertensive encephalopathy and sustained fetal bradycardia, leading to an emergent cesarean section where incidental chorioperitoneum was evidenced. Posterior abdominal CT control showed no alterations.Discussion: The main associated etiologies (malignancy and trauma) were ruled out. It is considered a presentation of spontaneous chyloperitoneum that could be related to the pelvic congestion of pregnancy due to: vasodilatation secondary to hormonal influence, increased intra-abdominal pressure and contribution of ascites due to preeclampsia, generating traumatic rupture of lymphatic vessels.Conclusion: Chylous ascites is a rare entity that can be associated with pregnancy. It is essential that gynecologist and obstetrician correctly approach these patients to determine the etiology early

Quiloperitoneo en diálisis peritoneal: reporte de caso y revisión sistemática de la literatura / Chyloperitoneum in peritoneal dialysis: a case report and review of literature

El quiloperitoneo es una condición infrecuente que se asocia a diálisis peritoneal; en la mayoría de los casos se puede confundir con peritonitis bacteriana, aunque puede ser la consecuencia de esta infección. Se reporta el desarrollo espontáneo de quiloperitoneo en un paciente de 54 años con enfermedad renal crónica secundaria a nefropatía diabética, en diálisis peritoneal manual desde hacía 5 años. El tratamiento consistió en suspensión temporal de la diálisis peritoneal, reposo intestinal, suministro de una dieta con alto contenido de ácidos grasos de cadena media e infusión de octreotide, con lo cual a los 10 días el paciente mostró mejoría, y se reinició la diálisis peritoneal. Una búsqueda sistemática de la literatura encontró 16 casos publicados (11 mujeres), con edades desde neonato hasta 88 años.

Chyloperitoneum is a rare condition associated with peritoneal dialysis. In most cases it is misdiagnosed as bacterial peritonitis, but it can also be a consequence of this infection. We present the spontaneous development of chyloperitoneum in a 54 year old patient with chronic kidney disease secondary to diabetic nephropathy, in manual peritoneal dialysis for 5 years. The treatment consisted of temporary suspension of peritoneal dialysis, bowel rest, supply of a diet with a high content of medium chain fatty acids and infusion of octreotide. After 10 days the patient showed improvement, and peritoneal dialysis was restarted. A systematic search of the literature found 16 published cases (11 women), ranging in age from newborn to 88 years.

Ascitis quilosa tras colecistectomía: presentación de un caso / Chylous ascites after cholecystectomy: case report and literatura review

INTRODUCCIÓN: La ascitis quilosa es la presencia de líquido linfático en la cavidad peritoneal. Como consecuencia de una cirugía abdominal es muy infrecuente, encontrando 5 casos previos en la literatura revisada tras colecistectomía. OBJETIVO: Presentar un caso clínico de ascitis quilosa poscolecistectomía, su manejo y una revisión de la literatura. MATERIALES Y MÉTODOS: Varón de 77 años, quiloperitoneo 21 días después de realización de colecistectomía programada por colecistitis aguda. Resultados: Se realiza drenaje percutáneo con débito de 5 L en 24 horas, se inicia octreótido subcutáneo y nutrición parenteral total. Al tercer día disminuye el débito por el drenaje, por lo que se inicia dieta rica en triglicéridos de cadena media con buena evolución posterior. De los 5 casos previos tras colecistectomía, el 60% se resolvió con tratamiento conservador, un paciente precisó reintervención y otro colocación de un shunt portosistémico intrahepático trasnyugular (TIPSS). CONCLUSIÓN: La ascitis quilosa es una complicación postquirúrgica infrecuente, encontrando solo 5 casos previos tras colecistectomía. Inicialmente el manejo debe ser conservador, en caso de persistencia se deben valorar otras medidas.

INTRODUCTION: Chylous ascites is defined as the presence of lymph fluid in the peritoneal cavity. It is a rare complication after abdominal surgery; only 5 previously reported cases were found after cholecystectomy. Aim: Present a case report and a literature review. MATERIALS AND METHOD: Case report of a 77 year old male who underwent an elective cholecystectomy due to acute cholecystitis. Chyloperitoneum showed up 21 days after surgery. RESULTS: We performed a percutaneous drainage and 5 L of fluid were removed in 24 hours. We started treatment with subcutaneous Octreotide and total parenteral nutrition. After 3 days drain output decreased and we started a medium-chain triglycerides diet with good progress. The outcome of 60% of the 5 previous case reports of chyloperitoneum after cholecystitis, were successful with conservative management, surgical intervention was needed in one patient and a transjugular intrahepatic portosystemic shunt (TIPSS) was placed in another patient. CONCLUSION: Chylous ascites is a rare complication after surgery, there are only 5 previously case reports after cholecystectomy. Conservative management has to be the first option and in case of persistence another therapy has to be considered.

Chylous Ascites Following Bariatric Surgery Report of Two Cases

Chylous ascites is a rare complication following bariatric surgeries. Little data is available regarding chylous ascites following bariatric surgeries per se or in association with internal hernias. Herein we present two cases of chylous ascites following Roux-En-Y gastric bypass; the first one is a 60-year-old male who was presented to the ER six months after a gastric bypass operation suffering from abdominal pain, CT scan and upper endoscopy were normal, however chylous ascites and internal hernia were found during exploratory laparoscopy. The second case is a 39-year-old female patient who was admitted three years following the gastric bypass operation and diagnosed to have small bowel obstruction due to internal hernia, and during exploratory laparoscopy a chylous ascites was found.

Resolution of Protein-Losing Enteropathy after Congenital Heart Disease Repair by Selective Lymphatic Embolization / 대한소아소화기영양학회지

With improving survival of children with complex congenital heart disease (CCHD), postoperative complications, like protein-losing enteropathy (PLE) are increasingly encountered. A 3-year-old girl with surgically corrected CCHD (ventricular inversion/L-transposition of the great arteries, ventricular septal defect, pulmonary atresia, post-double switch procedure [Rastelli and Glenn]) developed chylothoraces. She was treated with pleurodesis, thoracic duct ligation and subsequently developed chylous ascites and PLE (serum albumin ≤0.9 g/dL) and was malnourished, despite nutritional rehabilitation. Lymphangioscintigraphy/single-photon emission computed tomography showed lymphatic obstruction at the cisterna chyli level. A segmental chyle leak and chylous lymphangiectasia were confirmed by gastrointestinal endoscopy, magnetic resonance (MR) enterography, and MR lymphangiography. Selective glue embolization of leaking intestinal lymphatic trunks led to prompt reversal of PLE. Serum albumin level and weight gain markedly improved and have been maintained for over 3 years. Selective interventional embolization reversed this devastating lymphatic complication of surgically corrected CCHD.

Successful Treatment in a Newborn Infant with Chylous Ascites and Chylous Hydrocele

Chyle only occurs in the peritoneal cavity or around the pericardium through damage to the lymph nodes or improper drainage of the lymph and is characterized by a colostrum-like color and being rich in triglyceride. We encountered a case of a newborn infant with abdominal distention and further diagnosed chylous ascites and hydrocele by inspecting and analyzing the fluid obtained from the abdominal cavity and scrotum. Additionally, a lymphoscintigraphy was performed, which showed a decrease in the uptake of radioactive isotopes in the left iliac nodes and a delayed appearance. Here, we report a case of chyle diagnosed through puncture analysis and its subsequent successful treatment.

A case of follicular lymphoma accompanied with chylous ascites

No abstract available.

Ascitis quilosa postraumática tratada con nutrición parenteral total y octreótido / Post-trauma Chylous Ascites Treated with Total Parenteral Nutrition and Octreotide

La ascitis quilosa es la acumulación de quilo en la cavidad peritoneal por ruptura u obstrucción de los conductos linfáticos abdominales. Aunque es infrecuente, se describe mayor probabilidad de aparición después de traumas abdominales. Se presenta un paciente masculino de 46 años que sufre herida por arma blanca tóracoabdominal por lo que requirió tratamiento quirúrgico de urgencia. Luego de varias cirugías se constató la presencia de líquido abdominal blanquecino, con triglicéridos elevados. Se confirmó la ascitis quilosa, que se reabsorbió en 45 días con nutrición parenteral y octreótido(AU)

Chylous ascites is the accumulation of lipid-rich lymph in the peritoneal cavity due to rupture or obstruction of the abdominal lymph ducts. Although it is rare, greater probability is described for its onset after abdominal traumas. The case is presented of a 46-year-old male patient who suffers from a thorax-abdomen knife wound and therefore required emergency surgical treatment. After several surgeries, the presence of whitish abdominal liquid was detected, with elevated triglycerides. Chylous ascites was confirmed, which was reabsorbed in 45 days with parenteral nutrition and octreotide(AU)

Ascitis quilosa post cirugía abdominal: caso clínico y revisión de la literatura / Chylous ascites management: clinical case and literature review

Chylous ascites is a peritoneal collection with milky appearance, rich in triglycerides produced by the presence of thoracic or intestinal lymph in the abdominal cavity. The increasing number of surgical interventions has meant an increase of this disease in the last time. We present the case of a 39-yearsold woman with a history of a retroperitoneal cystic lesion in the abdominal ultrasound, which was a finding, and was followed up for 5 years. In the last control abdominal ultrasound showed an accelerated growth, the study was complemented with a Magnetic Resonance Imaging of the abdomen showed a retroperitoneal cystic lesion, 7 cm larger diameter in contact with aorta, left ureter and lower pole of the left kidney, suspecting malignancy, reason why its surgical resection was decided. It evolved after the surgical intervention with progressive increase of the abdominal perimeter, diffuse pain and early satiety, performing abdominal ultrasound showing a liver of normal structure with moderate ascites. The diagnostic paracentesis gave out 1,000 mL of milky-white liquid with triglycerides of 1,287 mg/dL. The diagnosis of chylous ascites was proposed, secondary to thoracic duct injury and it was managed with a diet with low intake of saturated, polyunsaturated and monounsaturated fats, with medium chain triglycerides with favorable results. The pathophysiology, etiology, nutritional and non-nutritional management of chylous ascites are discussed.

La ascitis quilosa es una colección peritoneal con apariencia lechosa, rica en triglicéridos producido por la presencia de linfa torácica o intestinal en la cavidad abdominal. El creciente número de intervenciones quirúrgicas ha significado un aumento de esta patología en el último tiempo. Se presenta el caso de una mujer de 39 años, con historia de una lesión retroperitoneal quística en la ecotomografía abdominal, que fue un hallazgo, realizándose seguimiento por 5 años. En la última ecotomografía de control presentó crecimiento acelerado por lo que se complementa estudio con una Resonancia Nuclear Magnética de abdomen que muestro lesión quística retroperitoneal de 7 cm de diámetro mayor en contacto con aorta, uréter izquierdo y polo inferior del riñón izquierdo, sospechándose malignidad, por lo que se decide su resección. Evolucionó posterior a la intervención quirúrgica con aumento progresivo del perímetro abdominal, dolor difuso y saciedad precoz, realizándose ecotomografía abdominal que muestra un hígado de estructura normal con ascitis moderada. La paracentesis diagnóstica dio salida a 1.000 mL de líquido blanquecino de aspecto lechoso con triglicéridos de 1.287 mg/dL. Se planteó el diagnóstico de ascitis quilosa, secundario a lesión del conducto torácico y se manejó con dieta con bajo aporte en grasas saturadas, poliinsaturadas y monoinsaturadas, con aporte de triglicéridos de cadena media con resultados favorables. Se discuten la fisiopatología, etiología, manejo nutricional y no nutricional de la ascitis quilosa.

Umbilical Venous Catheter Complication Presenting as Chylous Ascites in a Newborn: Intraperitoneal Extravasation of Total Parenteral Nutrition Infusate

Umbilical venous catheterization (UVC) is a common practice in intensive neonatal care. However, a malpositioned UVC and its prolonged use may lead to various problems, including mechanical, infectious, and thrombotic complications in various organs such as the liver, lungs, and heart. Congenital chylous ascites is characterized by abnormally high levels of triglycerides in the peritoneal fluid of newborns, which originate from refluxed lymph within the abdominal cavity. Herein, we report a case of an UVC complication presenting as chyloperitoneum simulating congenital chylous ascites in a preterm neonate that resulted from total parenteral nutrition (TPN) extravasation from a malpositioned UVC. Biochemical analysis of intraperitoneal chylous fluid and TPN infusate could help confirm the origin of chyloperitoneum. This case suggests that TPN extravasation from UVC should be considered when chyloperitoneum develops in newborns with an indwelling catheter. UVC positions must also be carefully monitored at regular intervals to recognize associated complications early, particularly in cases with an inevitably malpositioned catheter related to the anatomy of the vessel course.

Chylous ascites secondary to Hodgkin's lymphoma in a HIV/aids patient: case report and literature review

Study design: case report. Case report: Man, 42 years old, diagnosed with aids two years ago, had developed enlarging in abdominal volume six months from admission. Computed tomography imaging showed free liquid in peritoneal cavity and increased retroperitoneal and mesenteric lymph nodes, besides splenomegaly. Ascitic fluid had milky appearance and high triglycerides levels. Hodgkin's lymphoma (mixed cellularity) was confirmed by histopathological analysis of a video-laparoscopic lymph node biopsy, Ann Arbor IIIS staging. Chemotherapy and continuation of highly active antiretroviral therapy resulted in weight gain and reduction of abdominal volume. Chylous ascites is a rare condition, which has a vast differential diagnosis. Discussion: In our review, the majority (15/18, 83%) of chylous ascites in HIV/aids-patients are due to infectious causes (mainly Mycobacterium avium complex and tuberculosis infection), in highly immunocompromised patients (mean TCD4=87cell/mL). To the best of our knowledge, this is the first case of chylous ascites secondary to Hodgkin's lymphoma in a patient with aids. (AU)

Tipo de estudo: relato de caso. Relato de caso: Homem, 42 anos, diagnosticado com aids há dois anos, desenvolveu aumento de volume abdominal há seis meses da admissão. Tomografia computadorizada mostrou líquido livre na cavidade peritoneal, além de linfonodos mesentéricos e esplenomegalia. O líquido ascítico tinha aspecto leitoso e alto nível de triglicerídeos. Após amplo diagnóstico diferencial, diagnosticamos linfoma de Hodgkin tipo celularidade mista por biópsia linfonodal via videolaparoscópica, Ann Arbor IIIS. Quimioterapia e continuação da terapia antirretroviral de alta potência resultaram em ganho de peso e redução do volume abdominal. Ascite quilosa é uma entidade rara, que possui vários diagnósticos diferenciais. Discussão: Em nossa revisão, a maioria (15/18, 83%) dos casos de ascite quilosa em paciente com HIV/aids deveu-se a causa infecciosa (especialmente pelo Mycobacterium avium complex e tuberculose), em pacientes gravemente imunocomprometidos (linfócitos T-CD4 médio=84células/mm3). Até onde sabemos, este é o primeiro caso de ascite quilosa secundária a linfoma de Hodgkin em paciente com aids. (AU)

The key points of prevention for special surgical complications after radical operation of gastric cancer / 中华胃肠外科杂志

Incidence of gastric cancer is high in China and standard radical operation is currently the main treatment for gastric cancer. Postoperative complications, especially some special complications, can directly affect the prognosis of patients, even result in the increase of mortality. But the incidences of these special complications are low, so these complications are often misdiagnosed and delayed in treatment owing to insufficient recognition of medical staff. These special complications include (1) Peterson hernia: It is an abdominal hernia developed in the space between Roux loop and transverse colon mesentery after Roux-Y reconstruction of digestive tract. Peterson hernia is rare and can quickly result in gangrenous ileus. Because of low incidence and without specific clinical symptoms, this hernia does not attract enough attention in clinical practice, so the outcome will be very serious. Once the diagnosis is made, an emergent operation must be performed immediately. Peterson space should be closed routinely in order to avoid the development of hernia. (2) Lymphatic leakage: It is also called chyle leakage. Cisterna chylus is formed by gradual concentration of extensive lymphatic net to diaphragm angle within abdominal cavity. Lymphadenectomy during operation may easily damage lymphatic net and result in leakage. The use of ultrasonic scalpel can decrease the risk of lymphatic leakage in certain degree. If lymphatic leakage is found during operation, transfixion should be performed in time. Treatment includes total parenteral nutrition, maintenance of internal environment, supplement of protein, and observation by clamp as an attempt. (3)Duodenal stump leakage: It is one of serious complications affecting the recovery and leading to death after subtotal gastrectomy. Correct management of duodenal stump during operation is one of key points of the prevention of duodenal stump leakage. Routine purse embedding of duodenal stump is recommend during operation. The key treatment of this complication is to promt diagnosis and effective hemostasis.(4) Blood supply disorder of Roux-Y intestinal loop: Main preventive principle of this complication is to pay attention to the blood supply of vascular arch in intestinal edge. (5) Anastomotic obstruction by big purse of jejunal stump: When Roux-en-Y anastomosis is performed after distal radical operation for gastric cancer, anvil is placed in the remnant stomach and anastomat from distal jejunal stump is placed to make gastrojejunal anastomosis, and the stump is closed with big purse embedding. The embedding jejunal stump may enter gastric cavity leading to internal hernia and anastomotic obstruction. We suggest that application of interruptable and interlocking suture and fixation of stump on the gastric wall can avoid the development of this complication.

Comparison of complications following open, laparoscopic and robotic gastrectomy / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To compare clinically relevant postoperative complications after open, laparoscopic, and robotic gastrectomy for gastric cancer.</p><p><b>METHODS</b>Clinical data of patients with gastric cancer who underwent gastrectomy between January 1, 2014 and October 1, 2016 at Chinese People's Liberation Army General Hospital were analyzed retrospectively. All the patients were diagnosed by upper endoscopy and confirmed by biopsy without distant metastasis. They were confirmed with R0 resection by postoperative pathology. Patients with incomplete data were excluded. The complications among open group, laparoscopic group and robotic group were compared. The continuous variables were analyzed by one-way ANOVA, and categorical variables were analyzed by χtest or Fisher exact test.</p><p><b>RESULTS</b>A total of 1 791 patients (1 320 males and 471 females) were included in the study, aged from 17 to 98 (59.0±11.6) years, comprising 922 open, 673 laparoscopic and 196 robotic gastrectomies. There were no significant differences among three groups in baseline data (gender, age, BMI, comorbidity, radiochemotherapy) and some of operative or postoperative data (blood transfusion, number of lymph node dissection, combined organ resection, resection site, N stage, postoperative hospital stay). The blood loss in laparoscopic and robotic groups was significantly lower than that in open group[(185.7±139.6) ml and (194.0±187.6) ml vs. (348.2±408.5) ml, F=59.924, P=0.000]. The postoperative complication occurred in 197 of 1 791(11.0%) patients. The Clavien-Dindo II(, III(a, III(b, IIII(a, and IIIII( complications were 5.5%, 4.0%, 1.2%, 0.1%, and 0.2% respectively. The anastomotic leakage (2.4%), intestinal obstruction(1.3%) and pulmonary infection(1.2%) were the three most common complications, followed by wound infection(0.8%), cardiovascular disease(0.7%), anastomotic bleeding (0.7%), delayed gastric emptying (0.6%), duodenal stump fistula(0.5%), intraperitoneal hemorrhage (0.5%), pancreatic fistula (0.3%), intra-abdominal infection(0.2%), chylous leakage (0.1%) and other complications(1.7%). There were no significant differences among three groups as the complication rates of open, laparoscopic and robotic gastrectomy were 10.6%(98/922), 10.8%(73/673) and 13.3%(26/196) respectively (χ=1.173, P=0.566). But anastomotic leakage occurred more common after laparoscopic and robotic gastrectomy compared to open gastrectomy [3.1%(21/673) and 5.1%(10/196) vs. 1.3%(12/922), χ=12.345, P=0.002]. The rate of cardiocerebral vascular diseases was higher in open group[1.3%(12/922) vs. 0.1%(1/673) and 0, χ=8.786, P=0.012]. And the rate of anastomotic bleeding was higher in robotic group [2.0%(4/196) vs. open 0.4%(4/922) and laparoscopic 0.6%(4/673), χ=6.365, P=0.041]. In view of Clavien-Dindo classification, III(a complications occurred more common in laparoscopic group [5.5%(37/673) vs. open 3.3%(30/922) and robotic 2.6%(5/196), χ=6.308, P=0.043] and III(b complications occurred more common in robotic group [3.1%(6/196) vs. open 1.1%(10/922) and laparoscopic 0.7%(5/673), χ=7.167, P=0.028].</p><p><b>CONCLUSIONS</b>Morbidities of postoperative complications are comparable among open, laparoscopic and robotic gastrectomy for gastric cancer. However, in consideration of the high difficulty of anastomosis, the minimally invasive surgery should be performed by more experienced surgeons.</p>

A Case of Congenital Lymphatic Dysplasia Complicated by Hydrops Fetalis

Congenital lymphatic dysplasia is a rare congenital maldevelopment of the lymphatic system, in which dysfunction of the lymphatic system may cause leakage of lymph fluid into the limbs and the pleural, pericardial, or peritoneal cavity. We experienced a case of hydrops fetalis with subcutaneous lymphedema, chylothorax, chylous ascites and pericardial effusion. Lymphangiography revealed a critical defect of lymphatic system. Here, we report the first case of premature infant with congenital lymphatic dysplasia confirmed by lymphangiography, which is the first reported in Korea.