Lymphatic Chyle Duct Injury and Identification During Laparoscopic Sleeve Gastrectomy Preventing Postoperative Chylous Ascites.

We present a case of intraoperative detection of an iatrogenic chyle duct injury during laparoscopic sleeve gastrectomy. The chyle duct injury was identified and managed by ligature, preventing postoperative chylous ascites.

Preventing chylous ascites after right hemicolectomy with D3 extended mesenterectomy.

BACKGROUND: We aim to find the incidence of chylous ascites in patients undergoing D3 extended mesenterectomy and evaluate if a routine fat-reduced diet (FRD) has a prophylactic effect. METHODS: Data from 138 patients included in a D3 extended mesenterectomy trial were collected prospectively. Surgical drains and biochemical testing of drain fluid were used to find the incidence of chylous ascites among the first 39 patients, and a prophylactic fat-reduced diet was then implemented in the next 99 patients as a prophylactic measure. RESULTS: In the first 39 patients, we found that 16 (41.0%) developed chylous ascites. After the fat-reduced diet was implemented, 1 (1.0%) of 99 patients developed chylous ascites. Drain discharge was 150 vs. 80 mL daily, respectively, and a regression analysis shows the average leakage in the group with fat-reduced diet was 105 mL/day less than in the patients with no dietary restrictions (p < 0.001). There were no significant differences in the rate of other complications (Fisher exact test, one-tailed p = 0.8845), and although there was a tendency to a shorter hospital stay when given a fat-reduced diet (7.3 ± 5.4 vs. 8.9 ± 4.9 days), the difference was not significant (p = 0.19). CONCLUSIONS: Chylous ascites is a very common postoperative occurrence after right colectomy with extended D3 mesenterectomy and may be prevented using a routine fat-reduced diet.

The role of oral oil administration in displaying the chylous tubes and preventing chylous leakage in laparoscopic para-aortic lymphadenectomy.

BACKGROUND AND OBJECTIVES: This study is aimed to investigate the possibility of preoperative oral oil administration in displaying the chylous tubes and preventing chylous leakage in laparoscopic para-aortic lymphadenectomy. MATERIALS AND METHODS: In this retrospective nonrandomized study, of the 30 patients with gynecological malignancies who had indications for laparoscopic para-aortic lymphadenectomy up to renal vessels, 15 were administered preoperative oral oil (oil a administration) (control group) at our hospital between September 2017 and June 2018. The chylous tube displaying rates, incidences of chylous leakage, and other perioperative data of the two groups were compared. RESULTS: Successful display of chylous tubes was observed in 93.3% (14/15) patients in the oil administration group. The chylous leakage was zero in the oil administration group, and 33.3% (5/15) in the control group. The postoperative drainage duration (4.1 ± 1.0 days vs 7.6 ± 1.4 days, P = 0.000), somatostatin application time (0 day vs 5.9 ± 0.8 days), and postoperative hospital stay (6.0 ± 2.3 days vs 9.1 ± 2.1 days, P = 0.001) were significantly shorter in the oil administration group. The total cost is lower in the oil administration group (4972.52 ± 80.54 dollars vs 6260.80 ± 484.47 dollars, P = 0.000). CONCLUSIONS: Preoperative oil administration is a feasible and effective method to display the chylous tubes and to prevent the chylous leakage in para-aortic lymphadenectomy.

Does BLOODCARE Powder Prevent Postoperative Chylous Ascites After Lymphadenectomy for Gynecological Malignancies?

OBJECTIVE: The aim of this study was to evaluate the effect of an intraoperative hemostatic cellulose agent (BLOODCARE powder [Life Line, Brno, Czech Republic]) on reducing the incidence of postoperative chylous ascites (PCA) after complete pelvic and para-aortic lymphadenectomy (PPALN) in patients with gynecological cancers treated with laparotomy. METHODS: This case control study reviewed 150 patients with gynecological cancer who underwent PPALN. In the study group (n = 75), BLOODCARE powder was applied below the left renal vein and bilateral obturator fossa. In the control group (n = 75), no sealant agent was used after the procedure, such as fibrin glue or a hemostatic cellulose agent. RESULTS: The demographic and surgical characteristics of the patients in both groups were similar. Chylous ascites occurred in 9 cases (6%). The incidence of PCA was lower in the study group (1 [1.3%] vs 8 [10.7%]; P = 0.03). Logistic regression analysis indicated that using BLOODCARE powder during the surgery independently protected against the development of PCA. CONCLUSIONS: Using BLOODCARE powder during retroperitoneal surgery may prevent PCA. This simple, effective agent should be used after PPALN for gynecological cancers.

[The key points of prevention for special surgical complications after radical operation of gastric cancer].

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.

Management and prevention of chylous leakage after laparoscopic lymphadenectomy.

OBJECTIVE: To investigate the development and management of chylous leakage after laparoscopic retroperitoneal lymphadenectomy. PATIENTS AND METHODS: From July 2006 to September 2013, 13 cases of chylous leakage after the laparoscopic lymphadenectomy (6 cases of renal cell carcinoma, 4 cases of gastric cancer, 2 cases of ovarian cancer, 1 case of endometrial cancer) were studied to analyze the occurrence, development and management of chylous leakage. RESULTS: In 3 cases (2 cases of renal cell carcinoma, 1 case of gastric cancer) massive amount of milky fluid drainage was be seen after the first two days post operation. Dietary intervention, TPN (total parenteral nutrition), somatostatin therapy, maintenance of continuous drainage helped to successfully manage the condition in about 1 month duration. In the remaining 10 cases, chylous leakage appeared after restoring normal diet. Managed with changes in diet and maintenance of unobstructed drainage, they were cured in about 2 weeks after treatment. There was significant reduction in drain output, ultrasonography did not reveal presence of free fluid collection in abdomen, and the patients were in good condition without signs and symptoms of infections. CONCLUSIONS: Chylous leakage is a rare complication of retroperitoneal lymph node dissection. Surgeons should be familiar with laparoscopic techniques, relevant anatomy and be aware of the fact that the effect of CO2 pressure and use of ultrasonic knife to occlude the lymphatic vessel can transiently block the leakage making the surgeon overlook them. Routine placement of indwelling drainage tube, immediate diagnosis, dietary modification, TPN, somatostatin and drainage are the modalities of conservative management.

[Management of complications after residual tumor resection for metastatic testicular cancer]. / Komplikationsmanagement nach Residualtumorresektion bei metastasiertem Hodentumor.

Residual tumor resection (RTR) in patients with metastatic testicular cancer plays a pivotal role in a multimodal treatment. It can be performed unilaterally or as an extended bilateral RTR. Additional surgical procedures might be necessary, such as nephrectomy, splenectomy, partial colectomy, or vascular interventions with possible caval resection, cavotomy, or aortic resection with aortic grafting. Consequently, several complications can be seen in the intra- and postoperative course, most common of which are superficial wound infections, intestinal paralysis, lymphocele, and chylous ascites. We sought to describe complication management and how to prevent complications before they arise.

[Chylous leakage after retroperitoneoscopic upper-pole heminephrectomy for duplex kidney].

OBJECTIVE: To discuss management of chylous leakage after retroperitoneoscopic upper-pole heminephrectomy for duplex kidney. METHODS: Between November 2004 and Februar y 2011, 39 patients underwent retroperitoneoscopic upper-pole heminephrectomy for duplex kidney, of these 5 patients had chylous leakage. The ages of the patients ranged from 32 to 60 years (mean 42). All the patients were treated conservatively, and the therapeutic effects were observed. RESULTS: Delayed chylous leakage in 5 patients occurred 5-31 days after surgery, and leakage occurred in 4 of the same 5 patients during the first 2 post-operative years. Chylous leakage after retroperitoneoscopic upper-pole heminephrectomy for duplex kidney preferentially occurred at the left side of duplex kidney. All the patients healed under conservative treatment. CONCLUSION: Chylous leakage typically occurs after left retroperitoneoscopic upper-pole heminephrectomy for duplex kidney, and can be prevented by improving surgical technique; it can be completely relieved by conservative management with satisfactory results.

Milk-based test as a preventive method for chylous ascites following pancreatic resection.

BACKGROUND/PURPOSE: The incidence and natural history of postoperative chylous ascites are not well understood. This complication causes malnutrition and prolonged hospital stay. We investigated our institution's experience involving chylous ascites, especially following pancreatectomy. Additionally, we designed a new intraoperative method dubbed the 'milk test' for preventing chylous ascites. METHODS: Five cases of chylous ascites following pancreatectomy from April 2001 through March 2004 were studied retrospectively. The milk test was carried out prospectively. Such rates as positivity and incidence of ascites were examined. RESULTS: Of 65 cases (40 pancreatoduodenectomy; 25 distal pancreatectomy), 5 (7.7%) developed chylous ascites following pancreatic resection. All cases underwent octreotide and total parenteral nutrition treatment. From April 2004 through March 2009, the milk test was used in 104 cases. Surgical procedures comprised pancreatoduodenectomy (n = 78) and distal pancreatectomy (n = 23). Of these cases, 23 (22.1%) tested positive. No significant difference in positive rates was observed between the procedures and diseases. After initiation of the milk test, chylous ascites incidence decreased from 7.7 to 2.9%. CONCLUSIONS: For chylous ascites, octreotide and total parenteral nutrition treatments are useful. However, the milk test was found to be a safe and effective method for prevention of chylous ascites following pancreatectomy.

Value of prophylactic abdominal drainage in 1269 consecutive cases of elective liver resection.

BACKGROUND: The value of prophylactic abdominal drainage in patients undergoing hepatectomy is controversial. We carried out a retrospective study to clarify the value of this procedure. METHODS: The study subjects were 1269 consecutive patients who underwent elective hepatectomy with drain insertion for malignant tumors without associated gastrointestinal procedures or bilio-enteric anastomosis. Symptomatic abdominal fluid collections were treated by the drain salvage method, percutaneous puncture, and/or re-operation, in that order of preference. RESULTS: One patient died (mortality rate, 0.07%) and 7 patients had postoperative bleeding (0.6%). Bile leakage, found in 111 (8.7%) patients, subsided with retention of the drain in 78 (70%) and use of the drain salvage technique in 8 (7.2%), whereas percutaneous puncture and re-operation were required in 11 (9.9%) and 14 (12.6%). Symptomatic fluid collection, observed in 65 (5.1%) patients, was treated by the drain salvage technique in 20 (31%) patients, while puncture and re-operation were required in 25 (38%) and 20 (31%). CONCLUSIONS: Placement of drains was effective in a considerable proportion of patients undergoing hepatectomy, with regard to reducing the frequency of development of subphrenic fluid collections and biliary fistula/biloma formation.

Six cases of chylous leakage after axillary lymph node dissection.

BACKGROUND: Chylous leakage has been described after several surgical procedures, especially in the region of the neck and thorax. However, it has rarely been reported after axillary lymph node dissection. PATIENTS AND METHODS: We encountered 6 cases of chylous leakage after axillary lymph node dissection out of a total of 882 breast cancer patients between July 2005 and June 2007 in Shandong Provincial Hospital. These 6 cases were confirmed by axillary white fluid and chylomicron interpretation. The patients were treated conservatively, including a low fat diet, compression bandage, and suction drainage. RESULTS: All 6 cases were successfully treated without any complications such as infection, dystrophy, and lymphoceles. The chylous leakage disappeared within a median of 5 days (range: 3-7 days). Adjuvant chemotherapy and radiotherapy were not delayed. After a median follow-up period of 12 months (range: 6-20 months), no chronic complications were observed. CONCLUSION: Chylous leakage after axillary lymph node dissection is quite rare. It can be cured by conservative treatment. Lymphatic vessels should be identified carefully, and the main duct should be carefully ligated during surgical procedures, especially when level II and III lymph nodes are removed.

Fibrin glue application in the management of refractory chylous ascites in children.

The purpose of this retrospective review of the charts of 6 children who underwent surgical treatment of chylous ascites refractory to conservative measures between 1993 and 2006 was to evaluate the efficiency of fibrin glue application for control of lymph leakage. Five children had postoperative chylous ascites (neuroblastoma, 4; cystic lymphangioma, 1) and 1 had a congenital malformation. Surgical exploration revealed large areas of diffuse lymphatic leakage in all of the patients. Lymphatic fistula was not identified intraoperatively in any patient. Ingestion of lipophilic dye in a concentrated fatty meal was not helpful in locating a lymph fistula. Absorbable mesh was used in association with glue application in the last 3 patients treated. Control of ascites was achieved immediately in 2 patients and within 3 weeks in 2 patients. Repeat surgery was required in the remaining 2 patients. The mean follow-up time was 4.3 years. One patient died of tumor recurrence 12 months after surgical treatment without relapse of the ascites. Two mild late recurrences were observed at 6 and 11 months after surgery and were managed conservatively. The findings of this study show that fibrin glue application on absorbable mesh after dissection of the leakage zones is easy, safe, and effective. We recommend that surgery with glue application be repeated until control of ascites is achieved. We suggest fibrin glue application as a preventive measure against postoperative chylous ascites.

Review of incidence and management of chylous ascites after small bowel transplantation.

Nutrition management of intestinal transplant recipients continues to be a challenging and essential component of the early postoperative care of this patient population. The absorptive capacity of the graft can be affected by immunologic and nonimmunologic factors, including enteric lymphatic disruption, preservation injury, central denervation, viral enteritis, systemic infections, and rejection. Chylous ascites, the extravasation of milky chyle into the peritoneal fluid, defined by elevated triglycerides levels of > or = 200 mg/dL, can occur as a result of trauma, obstruction, or interruption of the lymphatic system. It seems the incidence of chylous ascites after small bowel transplantation is low; however, this may be due in part to the limitation of enteral long-chain triglycerides in the early posttransplant period of 2-6 weeks. After this time frame, clinical evidence suggests that fat assimilation normalizes. In the event that chylous ascites develop as a posttransplant complication, limitation of oral or enteral nutrition support to a very-low-fat regimen may be required, or parenteral nutrition (PN) will need to be provided until clinical status improves. Long-term posttransplant, lymphatic regeneration generally occurs and the majority of intestinal transplant recipients achieve the ultimate goal of nutrition autonomy.

Peri-operative chylous ascites.

Chylous ascites occurs when lymphatics are disrupted due to primary lymphatic disease, infection, malignancy, or chronic liver disease. It may also occur following inadvertent interruption of abdominal lymphatics during surgery involving retroperitoneal dissection. It is suggested by some that during liver transplantation, severed hepatic lymphatics should be ligated or stented to avoid post-operative pleural and abdominal accumulation of chylous fluid. The occurrence of chylous ascites and the need to ligate lymphatics after orthotopic transplantation was assessed in 180 consecutive patients subjected to this procedure. Pre-operative chylous ascites present in one patient resolved following transplantation. Three patients who required retroperitoneal dissection to complete the biliary anastomosis via choledochojejunostomy or perform a hepatic artery graft developed post-operative chylous ascites which rapidly resolved without complications. These findings indicate special attention to transacted hepatic lymphatics is not required during orthotopic liver transplantation. Chylous ascites rarely occurs after liver transplantation and its transitory development is due to retroperitoneal dissection.