External lymphatic fistula after intra-abdominal lymphadenectomy for cancer. Treatment with total parenteral nutrition and somatostatin.

OBJECTIVE: External lymphatic fistula or chyloperitoneum after intra-abdominal lymphadenectomy may present challenging problems. In the absence of definite guidelines the choice of treatment is often empirical, with unpredictable effectiveness, and the reporting of new cases may broaden the available experience. METHODS: We describe two cases. One patient had high-output external fistula (1300 mL/d) after para-aortic lymphadenectomy for metastatic lymph nodes. The fistula became fully evident at postoperative day 4, with resumption of an oral diet, on the basis of a 1300-mL/d output of white milky fluid from an abdominal drainage. Oral feeding was interrupted and total parenteral nutrition was started; this was transiently associated with octreotide administration, subsequently replaced by somatostatin. The second patient had a low-output fistula (350 mL/d) after liver resection and lymphadenectomy for cholangiocarcinoma and underwent treatment with total parenteral nutrition and somatostatin. RESULTS: In the first case the lymphatic fistula healed in just less than 3 wk, with the patient constantly remaining in very good condition, without secondary complications. In the second case the low-output fistula healed more rapidly. CONCLUSION: Interruption of oral feeding with total parenteral nutrition and continuous somatostatin infusion was an effective treatment in both patients with an intra-abdominal lymphatic leak.

Hanging maneuver in right hepatectomy for recurrent metastases with diaphragmatic infiltration after radiofrequency ablation: a new indication.

The liver hanging maneuver is a safe technique to prevent bleeding during transection when a right hepatectomy by an anterior approach, without previous mobilization of the liver, is required. This article proposes a new indication for this technique. The liver hanging maneuver may be useful during right hepatectomy for local recurrence of liver metastases previously treated by radiofrequency ablation (RFA). In these cases, necrosis or fibrosis induced by RFA and local recurrence may cause strong adhesions between liver parenchyma and the diaphragm, thus increasing the risk of bleeding during liver mobilization. Between January 2003 and March 2006, seven patients with recurrent colorectal liver metastases of the right hemiliver, after previous treatment by RFA, underwent right hepatectomy. Liver resection was feasible with the proposed technique in all patients. In four cases, a limited diaphragmatic resection was associated. There was no mortality. Postoperative morbidity was 42.8 per cent. An anterior approach with the liver hanging maneuver for recurrent liver metastases after RFA should be recommended when the metastases are located posteriorly, are not detachable from the diaphragm, and the preliminary mobilization of the right liver may be difficult.