Acute Chyloperitoneum with Small Bowel Volvulus: Case Series and Systematic Review of the Literature.

Introduction: Chyloperitoneum arises from lymph leakage into the abdominal cavity, leading to an accumulation of milky fluid rich in triglycerides. Diagnosis can be challenging, and mortality rates vary depending on the underlying cause, with intestinal volvulus being just one potential acute cause. Despite its rarity, our case series highlights chyloperitoneum associated with non-ischemic small bowel volvulus. The aims of our study include assessing the incidence of this association and evaluating diagnostic and therapeutic approaches. Material and Methods: We present two cases of acute abdominal peritonitis with suspected small bowel volvulus identified via contrast-enhanced computed tomography (CT). Emergency laparotomy revealed milky-free fluid and bowel volvulus. Additionally, we conducted a systematic review up to 31 October 2023, identifying 15 previously reported cases of small bowel volvulus and chyloperitoneum in adults (via the PRISMA scheme). Conclusions: Clarifying the etiopathogenetic mechanism of chyloperitoneum requires specific diagnostic tools. Magnetic resonance imaging (MRI) may be useful in non-emergency situations, while contrast-enhanced CT is employed in emergencies. Although small bowel volvulus infrequently causes chyloperitoneum, prompt treatment is necessary. The volvulus determines lymphatic flow obstruction at the base of the mesentery, with exudation and chyle accumulation in the abdominal cavity. Derotation of the volvulus alone may resolve chyloperitoneum without intestinal ischemia.

Sudan black poisoning resulted in methemoglobinemia in a baby with congenital chyloperitoneum.

Treatment of congenital chyloperitoneum is a challenge. Conservative methods may be ineffective. Preoperative visualization of the site of lymphatic leakage is crucial, but radiological imaging is technically complicated and may not provide sufficient information, especially in small patients. To ease the detection of lymphatic leakage during surgery, preoperative feeding with fat-rich formula with Sudan Black has been recommended. However, administration of Sudan Black may result in life-threatening methemoglobinemia and liver damage without any advantage of revealing leakage during surgery. We recommend preoperative feeding with pure fat-rich formula.

Rare Combination of Chyloperitoneum Secondary to Primary Small-Bowel Volvulus.

Chylous ascites is the exudation from lymphatic content to the peritoneum and is a rare situation that mostly occurs following medical causes like neoplasms or cirrhosis. However, trauma to the lymphatic system due to compression by masses or altered anatomy can be a trigger too. We describe a rare combination of a primary small bowel volvulus in a young healthy adult causing chylous ascites. Obstruction caused by a primary small bowell volvulus can re-arrange the lymphatics anatomy increasing their flow pressure which can lead to rupture and leak. This is an emergent scenario that needs to be addressed quickly because of bowel ischaemia. CT scan is the gold standard to expedite diagnosis and go to surgical treatment. Although it can be an impactful finding, treatment of the cause behind chylous ascites results in complete resolution without any bowel resection.

Chyloperitoneum After Penetrating Abdominal Trauma: A Report of a Rare Case.

The term chyloperitoneum refers to the accumulation of triglyceride-rich fluid in the peritoneal cavity. It is an uncommon clinical condition that usually occurs due to disruption of lymphatic flow secondary to trauma or obstruction. Common causes include penetrating or blunt trauma, iatrogenic injuries, congenital anomalies, malignant neoplasms, infections such as tuberculosis and filariasis, liver cirrhosis, constrictive pericarditis, congestive heart failure, inflammatory conditions, such as sarcoidosis and pancreatitis, and radiation- and drug-related pathologies. We present a case of chyloperitoneum in a 33-year-old woman secondary to penetrating abdominal trauma secondary to a gunshot wound. The patient was successfully managed with total parenteral nutrition and octreotide administration. To our knowledge, this is the only case of chylous ascites caused by a penetrating injury that has been reported in the literature. Conservative management with the initiation of total parenteral nutrition and octreotide led to the resolution of this condition.

Chyloperitoneum signifying late bowel obstruction following gastric clipping with proximal jejunal bypass: A case report.

Chyloperitoneum (CP) is a rare complication after bariatric surgery. We present a 37-year-old female with CP caused by a bowel volvulus following a gastric clipping with proximal jejunal bypass for morbid obesity. An abdominal CT image of a mesenteric swirl sign and abnormal triglyceride level of ascites fluid can confirm the diagnosis. In this patient, laparoscopy demonstrated dilated lymphatic ducts caused by a bowel volvulus resulting in the exudation of chylous fluid into the peritoneal cavity. After the reduction of bowel volvulus, she made an uneventful recovery with complete resolution of the chylous ascites. The presence of CP could indicate a situation of small bowel obstruction in patients with a history of bariatric surgery.

Quilotórax y abdomen agudo quiloso en el contexto de un vaciamiento ganglionar cervical / Chylothorax and chyloperitoneum in the setting of neck lymph node dissection

RESUMEN La presencia de quilotórax y de abdomen agudo quiloso luego de un vaciamiento ganglionar cervical izquierdo es una complicación muy poco frecuente. Se presenta el caso de una mujer de 24 años a quien se le realizó un vaciamiento ganglionar cervical bilateral por metástasis de carcinoma de tiroides. El segundo día del posoperatorio presentó dolor abdominal. Los estudios complementarios permitieron diagnosticar quilotórax y abdomen agudo quiloso, posiblemente como consecuencia de la ligadura inadvertida del conducto torácico. Se realizó el tratamiento médico y el drenaje percutáneo de ambas cavidades. Debido a buena evolución se indicó el alta hospitalaria con el drenaje abdominal, y continuar el seguimiento en forma ambulatoria. El tratamiento médico controlado para las lesiones del conducto torácico constituye la primera opción. En caso de mala evolución se debe pensar en la resolución quirúrgica sin demora.

ABSTRACT Chylothorax and chyloperitoneum after left lymph node dissection are rare complications. We report the case of a 24-year-old woman with a history of total thyroidectomy with bilateral lymph node dissection for metastases of papillary thyroid carcinoma. On postoperative day 2 the patient presented generalized abdominal pain. The complementary tests allowed for the diagnosis of chylothorax and chyloperitoneum. Medical treatment was started and percutaneous drainage of both cavities. The patient had favorable outcome and was discharged with the abdominal drain and indication of follow-up in the outpatient clinic. Supervised medical treatment for thoracic duct injuries constitute the first treatment option. Surgery should not be delayed in case of poor outcome.

Chyloperitoneum in Peritoneal Dialysis Secondary to Calcium Channel Blocker Use: Case Series and Literature Review.

Chyloperitoneum (chylous ascites) is a rare complication of peritoneal dialysis (PD). Its causes may be traumatic and nontraumatic, associated with neoplastic disease, autoimmune disease, retroperitoneal fibrosis, or rarely calcium antagonist use. We describe six cases of chyloperitoneum occurring in patients on PD as a sequel to calcium channel blocker use. The dialysis modality was automated PD (two patients) and continuous ambulatory PD (the rest of the patients). The duration of PD ranged from a few days to 8 years. All patients had a cloudy peritoneal dialysate, characterized by a negative leukocyte count and sterile culture tests for common germs and fungi. Except for in one case, the cloudy peritoneal dialysate appeared shortly after the initiation of calcium channel blockers (manidipine, n = 2; lercanidipine, n = 4), and cleared up within 24-72 h after withdrawal of the drug. In one case in which treatment with manidipine was resumed, peritoneal dialysate clouding reappeared. Though turbidity of PD effluent is due in most cases to infectious peritonitis, there are other differential causes including chyloperitoneum. Although uncommon, chyloperitoneum in these patients may be secondary to the use of calcium channel blockers. Being aware of this association can lead to prompt resolution by suspension of the potentially offending drug, avoiding stressful situations for the patient such as hospitalization and invasive diagnostic procedures.

Milky Ascites: A Diagnostic Dilemma.

Chylous ascites is a milky-appearing, triglyceride-rich fluid within the abdominal cavity. It is a rare finding that arises from the disruption of the lymphatic system and can be caused by a wide variety of pathologies. Here, we present a diagnostically challenging case of chylous ascites. In this article, we discuss the pathophysiology and various etiologies of chylous ascites, explore the diagnostic tools available, and highlight the management strategies implemented in this rare finding.

Chyloperitoneum and Chylothorax Following Bariatric Surgery: a Systematic Review.

Chyloperitoneum and chylothorax (ChP/ChT) are rare complications after bariatric surgery. This systematic review aims to evaluate the incidence, cause, treatment, and outcome of ChP and ChT after bariatric surgery. This review investigates published English language scientific literature systematically in an attempt to answer these questions. Our literature search revealed 66 studies, of which 23 were included. There were a total of 40 patients (38, ChP; 2, ChT). Eighteen of 40 (43.9%) patients were treated laparoscopically, and one patient (2.44%) underwent thoracoscopy and ligation of the thoracic duct. Both ChP and ChT are rare complications after bariatric surgery.

Abdomen agudo por ascitis quilosa secundaria a pancreatitis aguda: reporte de un caso

La ascitis quilosa (AQ) es una entidad rara, y puede manifestarse como una reacción peritoneal llamada peritonitis quilosa aguda (PQA). Presentamos el caso de un varón de 26 años, con cuadro abdominal agudo, por lo que es intervenido quirúrgicamente, encontrándose líquido lechoso turbio, en cavidad abdominal, realizándose una apendicectomía profiláctica, aspiración y lavado de cavidad, con colocación de drenajes. El análisis de líquido mostró aumento de triglicéridos y amilasa, gram y cultivos negativos; y la tomografía reveló una pancreatitis aguda (Baltazar C), todo ello confirmando el diagnóstico de AQ secundaria a pancreatitis. Paciente cursa con una evolución favorable con hidratación, analgésicos y dieta vía oral a tolerancia. En la literatura se han descrito muy pocos casos de PQA, y su asociación con pancreatitis aguda es bastante inusual. Pudiendo simular un cuadro abdominal agudo quirúrgico, cuyo tratamiento consiste en la exploración quirúrgica con drenaje peritoneal, pudiendo o no, requerir apoyo nutricional.

Chylous ascites (CA) is a rare condition, and it can present as a peritoneal reaction named acute chylous peritonitis (ACP). We report the case of a 26-year old male who developed acute abdomen. He underwent surgery and turbid milky fluid was found in his abdominal cavity. A prophylactic appendectomy was performed, as well as aspiration and lavage of the abdominal cavity. Drainage tubes were placed. Studies of the fluid revealed increased triglyceride and amylase contents. Gram-staining and cultures were negative. A computed tomography scan revealed acute pancreatitis (Balthazar C), so a diagnosis of chylous ascites secondary to pancreatitis was confirmed. The patient did well, he received hydration, analgesics, and oral diet according to tolerance. Very few cases of ACP have been reported in the literature, and its association with acute pancreatitis is very unusual. This condition may resemble surgical acute abdomen, and its management includes surgical exploration with peritoneal drainage. Nutritional support may also be needed.

An unusual case of a persistent, infected retroperitoneal fluid collection 5 years after anterior lumbar fusion surgery: illustrative case.

BACKGROUND: Anterior lumbar fusion procedures have many benefits and continue to grow in popularity. The technique has many potential approach- and procedure-related complications. Symptomatic retroperitoneal fluid collections are uncommon but potentially serious complications after anterior lumbar procedures. Collection types include hematomas, urinomas, chyloperitoneum, cerebrospinal fluid collections, and deep infections. OBSERVATIONS: The authors present an unusual case of a patient with persistent symptoms related to a retroperitoneal collection over a 5-year period following anterior lumbar fusion surgery. To the authors' knowledge, no similar case with such extensive symptom duration has been described. The patient had an infected encapsulated fluid collection. The collection was presumed to be a postoperative lymphocele that was secondarily infected after serial percutaneous drainage procedures. LESSONS: When retroperitoneal collections occur after anterior retroperitoneal approaches, clinical clues, such as timing of symptoms, hypotension, acute anemia, urinary tract infection, hydronephrosis, elevated serum creatinine and blood urea nitrogen, low-pressure headaches, anorexia, or systemic signs of infection, can help narrow the differential. Retroperitoneal collections may continue to be symptomatic many years after anterior lumbar surgery. The collections may become infected after serial percutaneous drainage or prolonged continuous drainage. Encapsulated, infected fluid collections typically require surgical debridement of the capsule and its contents.

Combined endolymphatic and surgical treatment of a leaking central conducting lymphatic malformation in a neonate.

Lymphatic malformations are congenital alterations of normal embryonic lymphatic development. We present a case of a premature 7-week-old male with a large central conducting lymphatic malformation and significant abdominal chylorrhea. He was successfully treated with combined endolymphatic and surgical approaches. To the authors' knowledge, this is the first case to be described.

Chyloperitoneum following open myelomeningocele repair: dealing with an extremely rare finding.

PURPOSE: Chyloperitoneum is an extremely rare finding following myelomeningocele (MMC) repair in neonates. We aimed to describe the characteristics of such a case and explore its clinical significance. CASE REPORT: A male baby born at term with open MMC and hydrocephalus underwent MMC repair surgery with rotational flaps on the first postnatal day. The procedure was uneventful. Three days later, he underwent a right ventriculoperitoneal shunt (VPS) insertion. On opening the peritoneum, a remarkable amount of yellowish opaque fluid was observed. Chyloperitoneum was suspected, but the VPS procedure was completed as planned. Biochemical analysis was consistent with that of chyle. DISCUSSION: Neonatal chylous ascites is a rare condition; hence, available data on pathophysiology and therapy in the literature are scarce. It is postulated that the MMC repair in neonates causes abdominal tautness, which leads to rupture of small lymphatics and raised intraportal pressure. The combination of these two processes results in extravasation of chyle from the gastrointestinal tract. Presence of chyloperitoneum is not a contraindication for VPS insertion. CONCLUSION: Chyloperitoneum is an extremely rare sequela of MMC repair in neonates. Pediatric neurosurgeons should be aware of it, especially when a VPS procedure is to follow a repair, in order to know how to deal with it and avoid unnecessary abandonment of the shunt.

Clinical feature and outcomes analysis in 25 cases of newborns with congenital chylothorax and chyloperitoneum / 国际儿科学杂志

Objective:To investigate the clinical features and outcome of congenital chylothorax and chyloperitoneum ascites in infants.Methods:The clinical data of infants admitted to the Neonatal Department of Shengjing Hospital of China Medical University and diagnosed with congenital chylothorax and chyloperitoneum from January 2011 to December 2018 were analyzed retrospectively.According to outcome, the infants were assigned into survival group and death group.The clinical characteristics between the two groups were compared.Results:The total cases were 25(the ratio of male to female is 3.2). The gestational age ranged from 30 to 39 weeks, and the birth weight was 1 620 to 4 770 g. There were twenty infants were diagnosed before delivery accounted for 80%.Five infants(20%)presented with fetal edema.There were twenty-one infants were diagnosed with congenital chylothorax(84.0%, 5 with chyloperitoneum). Fourteen cases of congenital chylothorax were bilateral(66.7%), seven infants were unilateral, six infants(85.7%)were right-sided chylothorax.There four infants(16.0%)were diagnosed with chyloperitoneum.There were fifteen cases in the survival group, including eleven cases of chylothorax(73.3%), three cases of chyloperitoneum(20.0%), and one case of chylothorax combined with chyloperitoneum(6.7%). There were ten cases in the death group, all of which were premature infants, including nine cases of chylothorax and seven cases of bilateral chylothorax(70.0%). The median gestational age(33w)and birth weight(2 486 g)of the death group was significantly lower than the survival group(38w and 3 342 g), and the median gestational age when prenatal diagnosis[(30±1)weeks]was significantly lower than the survival group[(34±1)weeks]. The difference between the two groups was statistically significant( P<0.05). The proportion of mechanical ventilation in the death group was significantly higher than the survival group( P<0.05). Conclusion:The gestational age, birth weight, and the time of intrauterine diagnosis affect the outcome of congenital chylothorax and chyloperitoneum.The mortality rate is higher in premature, lower gestational age at the time of intrauterine diagnosis and bilateral chylothorax.

Chyle Leakage after Esophageal Cancer Surgery.

Surgeons recommend dissecting lymph nodes in the thorax, abdomen, and neck during surgery for esophageal cancer because of the possibility of metastasis to the lymph nodes in those areas through the lymphatic plexus of the esophageal submucosal layer. Extensive lymph node dissection is essential for accurate staging and is thought to improve survival. However, it can result in several complications, including chyle leakage, which refers to continuous lymphatic fluid leakage and can occur in the thorax, abdomen, and neck. Malnutrition, fluid imbalance, and immune compromise may result from chyle leakage, which can be potentially life-threatening if it persists. Therefore, various treatment methods, including conservative treatment, pharmacological treatment such as octreotide infusion, and interventions such as thoracic duct embolization and surgical thoracic duct ligation, have been applied. In this article, the risk factors, diagnosis, and treatment methods of chyle leakage after esophagectomy are reviewed.

Magnetic Resonance Lymphangiography.

Dynamic contrast-enhanced magnetic resonance lymphangiography is a novel technique to image central conducting lymphatics. It is performed by injecting contrast into groin lymph nodes and following passage of contrast through lymphatic system using T1-weighted MR images. Currently, it has been successfully applied to image and plan treatment of thoracic duct pathologies, lymphatic leaks, and other lymphatic abnormalities such as plastic bronchitis. It is useful in the assessment of chylothorax and chyloperitoneum. Its role in other areas such as intestinal lymphangiectasia and a variety of lymphatic anomalies is likely to increase.

High-output chyloperitoneum following laparoscopic Nissen fundoplication treated with retrograde transvenous thoracic duct embolization.

BACKGROUND: Iatrogenic injury of the thoracic duct with clinical significant chyloperitoneum is a rare complication of abdominal surgery. Chyloperitoneum following laparoscopic Nissen fundoplication has been described in a few cases only. Most interventionists use the antegrade transperitoneal approach for thoracic duct embolization. CASE PRESENTATION: A 61-year-old woman had been operated with laparoscopic Nissen fundoplication and hiatoplasty. A few weeks later she presented with high-output chyloperitoneum due to large leakage of the proximal thoracic duct. Conservative treatment and conventional transnodal lymphangiography did not result in a significant improvement. Thoracic duct embolization via retrograde transvenous access was challenging but both technically and clinically successful. CONCLUSION: To the best of our knowledge, this is the first case-report about thoracic duct embolization with retrograde transvenous access in the rare situation of chylous ascites following laparoscopic fundoplication. Thoracic duct embolization with the seldom used retrograde transvenous access may be the more physiologic and safer route in doing this and might be used as treatment of first choice.

The Use of Indocyanin Green for Peroperative Diagnostic of Chylous Ascites and Autologous Tissue Glue (Vivostat) for the Treatment.

BACKGROUND: Chylous ascites or chyloperitoneum can be caused by peroperative injury of the lymphatic pathways; the lymph is accumulated in the abdominal cavity. The incidence of chylous ascites varies according to the type of surgery and the extent of the lymphadenectomy. The first choice of treatment is a conservative procedure - total parenteral nutrition or a strict low-fat diet. If this fails, a surgical revision is indicated. However, this is often difficult due to postoperatively altered terrain and the chronic presence of pathological secretion in the abdominal cavity. The application of a fat emulsion or indocyanine green (ICG) to the lymphatic drainage area may help identify the lymph source. Nowadays, ICG is used in various clinical indications, e.g. evaluation of liver function, angiography in ophthalmology, assessment of blood supply to the tissues, search for lymph nodes in oncological surgeries. The advantage of ICG lymphography is the possibility of observing the source of the leak in real time directly during surgical revision. CASE REPORT: A polymorbid 66-year-old patient after radical oncogynaecological surgery with aortopelvic lymphadenectomy was postoperatively complicated by persistent, high-volume chylous ascites, not responding to conservative treatment. Therefore, we performed surgical revision of the abdominal cavity and successful treatment of the leak source using ICG peroperative lymphography and subsequent application of Vivostat autologous tissue glue to this area. CONCLUSION: High-volume consistent chylous ascites is not a frequent postoperative complication but it has a significant impact on the quality of life, nutritional status of the patient and further patient prognosis. The treatment is strictly individual. The first choice should be a conservative approach. Where that fails, a difficult surgical revision is indicated. Today, however, the surgeon can be helped by modern technologies such as fluorescent navigated surgery or treatment of the source with autologous tissue adhesives. The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedice papers.

Chyloperitoneum secondary to internal herniation complicating omega-loop gastric bypass.

Chyloperitoneum is a potential complication of omega-loop gastric bypass caused by internal herniation. Chronic compression of the mesentery leads to chylous extravasation that can mimic peritonitis.

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.