Incomplete lymphatic sealing around the inferior mesenteric artery is a risk factor for chylous ascites in robotic rectal cancer surgery.

INTRODUCTION: Compared with laparoscopic surgery (LS), robotic surgery (RS) is considered to have acceptable outcomes in rectal cancer, but few reports have focused on chylous ascites in RS. The aim of this study was to investigate the incidence and etiology of chylous ascites after RS. METHODS: This retrospective study included 291 patients with rectal cancer who underwent RS (n = 165) or LS (n = 126) with high ligation of the inferior mesenteric artery (IMA). Propensity score matching (PSM) was performed to compare the two groups. RESULTS: \Dissection around the IMA was achieved using ultrasonic coagulating shears in most LS cases, and monopolar scissors in most RS cases, sometimes using bipolar vessel sealing device or bipolar forceps. The incidence of chylous ascites was 12.2% in RS and 4.1% in LS after PSM (P = .037). When limited to the RS group, multivariate analysis identified absence of lymphatic sealing at the left side of the IMA and shorter operative time as independent risk factors for chylous ascites. Except for duration of drain placement, no outcomes differed significantly with or without chylous ascites. One patient with chylous ascites developed later infection and required antibiotic treatment. CONCLUSION: The incidence of chylous ascites is significantly higher in RS than in LS, and RS with incomplete lymphatic sealing around the IMA is a risk factor for chylous ascites in rectal cancer. Although outcomes for patients with chylous ascites were acceptable, adequate lymphatic sealing during dissection around the IMA is crucial to prevent chylous ascites in RS.

Prediction of prolonged resolution of chylous ascites after radical D3 resection for colorectal cancer: A population-based experience from a high-volume center.

AIM: This study was aimed to analyze the incidence, risk factors, and management of chylous ascites (CA) after radical D3 resection for colorectal cancer, and to construct a predicting nomogram for prolonged resolution of CA. METHOD: Consecutive colorectal cancer patients who underwent radical D3 resection were included. Logistic analysis was used to identify risk factors of postoperative CA, as well as prolonged CA resolution. A predictive nomogram for prolonged resolution of CA was developed and validated internally. RESULTS: Among 7167 patients included, 277 (3.8%) patients developed CA. Logistic regression analysis demonstrated that laparoscopic operation (OR 1.507; P = 0.017) and tumors fed by the superior mesenteric artery (SMA, OR 2.456; P < 0.001) were independent risk factors of postoperative CA following radical D3 surgery for colorectal cancer. Open operation (OR 0.422; P = 0.027), drainage output on the first day of treatment (OR 1.004; P = 0.016), time to oral intake (OR 1.273; P = 0.042), and time to onset (OR 1.231; P = 0.024) were independently associated with prolonged resolution of postoperative CA (≥7 days). A predictive nomogram for prolonged CA resolution was developed with a C-index of 0.725. CONCLUSION: The incidence of CA after radical D3 surgery of colorectal cancer was 3.8%. Open operation, drainage output on the first day of treatment, time to oral intake, and time to onset were independently associated with prolonged resolution of postoperative CA. A nomogram may assist in tailored treatment decision-making and counseling patient with treatment strategies.

Clinical characteristics of systemic lupus erythematosus with chylothorax and/or chylous ascites: An analysis of 15 cases in China.

ABSTRACT: This analysis of clinical data from systemic lupus erythematosus (SLE) patients with chylothorax and/or chylous ascites was conducted to guide further clinical work.From June 2008 to June 2019, 15 SLE patients (14 females and 1 male) with chylothorax and/or chylous ascites were hospitalized at the Beijing Shijitan Hospital. Sixty SLE patients without chylothorax and chylous ascites were randomly selected as controls. Patients', clinical data was investigated.The mean age of onset of chylothorax and/or chylous ascites in patients with SLE was 35.7 ±â€Š3.7 years (range, 15-69 years). The mean disease duration of chylothorax and/or chylous ascites in patients with SLE was 13.7 ±â€Š3.4 months (range, 1-48 months). Patients with chylothorax and/or chylous ascites were always diagnosed at later stages of SLE compared with the controls. Among cases, glomerulonephritis and hematologic system involvement were the most common complications. Anti-Sjogren's syndrome antigen A antibody was positive in 7 cases (46.7%). Among cases, direct lymphangiography was performed in 13 patients, indicating thoracic duct outlet obstruction or a poor backflow at the terminal of the thoracic duct. Subsequently, 13 patients were treated with corticosteroids, combined with immunosuppressants in 11 patients and thoracic duct surgery in 6 patients. Eleven patients were followed up for 0.5 to 7.0 years. One patient died of infection. Eight patients (53.3%) achieved remission.Chylothorax and/or chylous ascites are rare complications of SLE. An early diagnosis and timely initiation of glucocorticoids, immunosuppressants, and surgery are critical to relieve symptoms and to improve prognosis.

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.

Diagnosis, Outcome, and Management of Chylous Ascites Following Pediatric Liver Transplantation.

Data on postoperative chylous ascites (CA) after pediatric liver transplantation (LT) are scarce. This retrospective study was conducted to identify the incidence, risk factors, management, and outcomes of postoperative CA in a large single-center pediatric LT cohort (2000-2016). The study cohort comprised 317 LTs (153 living donors and 164 deceased donors) in 310 recipients with a median age of 2.7 years. The incidence of CA was 5.4% (n = 17), diagnosed after a median time of 10 days after LT. Compared with chylomicron detection in peritoneal fluid (the gold standard), a triglyceride cutoff value of 187 mg/dL in peritoneal fluid showed insufficient sensitivity (31%) for CA diagnosis. In univariate logistic regression analyses, ascites before LT, younger age, and lower weight, height, and height-for-age z score at LT were associated with CA. Symptomatic management of CA included peritoneal drain (100%) and diuretics (76%). Therapeutic interventions included very low-fat or medium-chain triglyceride-rich diets (94%) and intravenous octreotide (6%), leading to CA resolution in all patients. CA was associated with prolonged hospital length of stay (LOS; 40 days in the CA group versus 24 days in the non-CA group; P = 0.001) but not with reduced patient or graft survival rates after a median follow-up time of 14 years. In conclusion, CA in the pediatric LT recipient is a relatively uncommon complication associated with increased hospital LOS and morbidity. Measurement of chylomicrons is recommended in patients with ascites that is more severe or persistent than expected. Dietary interventions are effective in most patients.

Incidence of chyloabdomen diagnosis in dogs and cats and corresponding clinical signs, clinicopathologic test results, and outcomes: 53 cases (1984-2014).

OBJECTIVE To determine the incidence of chyloabdomen diagnosis in cats and dogs and characterize and compare between species the corresponding clinical signs, clinicopathologic test results, and outcomes. DESIGN Retrospective case series. ANIMALS 36 cats and 17 dogs in which chyloabdomen was diagnosed at a veterinary teaching hospital between 1984 and 2014. PROCEDURES Medical records were reviewed, and data retrieved included patient signalment; clinical signs at initial evaluation; results of physical examination, diagnostic tests, and imaging studies; and outcomes. Survival analyses, descriptive statistics, and comparisons between species were completed. RESULTS The incidence of chyloabdomen at the veterinary teaching hospital during the study period was 2.0 cases/100,000 admissions for cats and 2.8 cases/100,000 admissions for dogs. The mean age at diagnosis of chyloabdomen in cats was 11.3 years, compared with 6.9 years in dogs. The most common clinical signs in dogs and cats combined were lethargy (39/51 [76%]) and anorexia (37/51 [73%]), but fewer (23/53 [43%]) had abdominal distention. Chylothorax was a common comorbidity (25/53 [47%]), with malignant neoplasia being the most common underlying diagnosis (24/53 [45%]). Survival analyses included 44 patients; median survival time from diagnosis of chyloabdomen was 31 days overall, 8 days for patients with malignant neoplasia, and 73 days for patients without neoplasia. CONCLUSIONS AND CLINICAL RELEVANCE There were multiple causes of chyloabdomen in dogs and cats of the study, and outcome depended on underlying cause. Because of this and the rarity of chyloabdomen, a multicenter prospective study of disease progression, treatment response, and clinical outcome for dogs and cats with chyloabdomen is needed.

A Proposed Classification System and Therapeutic Strategy for Chyle Leak After Laparoscopic Living-Donor Nephrectomy: A Single-Center Experience and Review of the Literature.

OBJECTIVES: Chyle leak or chylous ascites remains a rare complication after laparoscopic living-donor nephrectomy. Its cause and management have not been well elucidated in the literature. Thus, the aim of this study was to review the incidence of chyle leak/chylous ascites after laparoscopic living-donor nephrectomy in our institute and in the literature to propose a classification system with its associated treatment strategy. MATERILAS AND METHODS: In this retrospective review of laparoscopic living-donor nephrectomy patients from January 2005 to April 2016, we identified patients with chyle leak/chylous ascites along with the care performed. A proposed classification system based on our experience and literature is described. RESULTS: Chylous leak developed in 4 donors (2.25%). Of the 4 donors, 3 were treated nonoperatively with diet modification and subcutaneous octreotide injection. One patient required surgical intervention after not responding to second-line therapy with total parenteral nutrition. CONCLUSIONS: Chyle leak/chylous ascites after laparoscopic living-donor nephrectomy is rare, but a delayed diagnosis may lead to morbidity secondary to malnutrition and immunosuppression. Meticulous surgical dissection is essential to seal the lymphatic tubes during laparoscopic living-donor nephrectomy. The proposed classification system provides a practical and tailored guide to management based on the drainage volume of chyle leak and a guide to the earlier identification of refractory cases.

The incidence of chylous ascites after liver transplantation and the proposal of a diagnostic and management protocol.

BACKGROUND: No protocol has been established for the diagnosis and management of chylous ascites after liver transplantation (LT). In this study, we retrospectively reviewed our cases of posttransplant chylous ascites (PTCA) and aimed to propose a diagnostic and management protocol. PATIENTS AND METHODS: We retrospectively reviewed the clinical records of 96 LT recipients who underwent LT at our department. The incidence of PTCA and the associated risk factors were analyzed and our protocol for chylous ascites was evaluated. RESULTS: PTCA occurred in 6 (6.3%) patients (mean age: 10.7±11.0years) at a mean of 10.8±3.6days after LT. The primary disease in all of PTCA cases was biliary atresia (BA). The periportal lymphadnopathy was an independent risk factor for PTCA. In all cases PTCA successfully resolved according to our protocol. Octreotide was administered in 4 of our 6 PTCA cases. The mean postoperative hospital stay was 40.2±8.4days, which was similar to that of cases without PTCA. CONCLUSIONS: The incidence of PTCA in LT patients, especially in those with BA, is relatively high. Our diagnostic criteria and our management protocol were helpful for patients with refractory ascites after LT. TYPE OF STUDY: Diagnostic test: Level II. Treatment study: Level III.

[Comparison of complications following open, laparoscopic and robotic gastrectomy].

OBJECTIVE: To compare clinically relevant postoperative complications after open, laparoscopic, and robotic gastrectomy for gastric cancer. METHODS: 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 χ2 test or Fisher exact test. RESULTS: 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 (χ2=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), χ2=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, χ2=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), χ2=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), χ2=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), χ2=7.167, P=0.028]. CONCLUSIONS: 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.

[CHYLOUS LEAKAGE AFTER LAPAROSCOPIC RENAL AND ADRENAL SURGERY].

(Objectives) It is recognized that Chylous leakage is a rare complication but is a relevant clinical problem after major abdominal surgery. It was occasionally reported in urologic surgery, but the data about its incidence and treatment outcome is still lacking. In this study, we reviewed our cases of chylous leakage after laparoscopic adrenalectomy or nephrectomy. (Patients and methods) From January 2005 to September 2014, laparoscopic adrenalectomies or nephrectomies were performed in 300 patients. The factors that affected the development of chylous leakage were analyzed. (Results) The overall incidence of chylous leakage was 4.3% (13 of 300 cases). All chylous leakage was seen on the left side, and it was commonly developed in patients with lymph node dissection or excessive hilar dissection around the left renal pedicle. Importantly, all cases were successfully managed conservatively by a low fat diet with or without octreotide. (Conclusions) Our results suggest that chylous leakage is not a rare complication after laparoscopic adrenalectomy or nephrectomy, but most cases can be treated conservatively. Chylous leakage can occur in patients with lymphadenectomy or hilar dissection on the left side.

Small-volume chylous ascites after laparoscopic radical gastrectomy for gastric cancer: results from a large population-based sample.

AIM: To report the incidence and potential risk factors of small-volume chylous ascites (SVCA) following laparoscopic radical gastrectomy (LAG). METHODS: A total of 1366 consecutive gastric cancer patients who underwent LAG from January 2008 to June 2011 were enrolled in this study. We analyzed the patients based on the presence or absence of SVCA. RESULTS: SVCA was detected in 57 (4.17%) patients, as determined by the small-volume drainage (range, 30-100 mL/24 h) of triglyceride-rich fluid. Both univariate and multivariate analyses revealed that the total number of resected lymph nodes (LNs), No. 8 or No. 9 LN metastasis and N stage were independent risk factors for SVCA following LAG (P<0.05). Regarding hospital stay, there was a significant difference between the groups with and without SVCA (P<0.001). The 3-year disease-free and overall survival rates of the patients with SVCA were 47.4% and 56.1%, respectively, which were similar to those of the patients without SVCA (P>0.05). CONCLUSION: SVCA following LAG developed significantly more frequently in the patients with ≥32 harvested LNs, ≥3 metastatic LNs, or No. 8 or No. 9 LN metastasis. SVCA, which was successfully treated with conservative management, was associated with a prolonged hospital stay but was not associated with the prognosis.

Chylous ascites following retroperitoneal lymphadenectomy in gynecologic malignancies: incidence, risk factors and management.

INTRODUCTION: Chylous ascites is a rare form of ascites that results from accumulated lymph fluid in the peritoneal cavity caused by blocked or disrupted lymph flow through the major lymphatic channels. In the present study, our aim was to analyze the incidence, risk factors, diagnostic evaluation and management of chylous ascites after lymphadenectomy in gynecologic malignancies. METHODS: A total of 458 patients who had undergone staging surgery for gynecologic malignancies at our institution between January 2010 and December 2013 were retrospectively reviewed. After the exclusion criteria were applied, 399 patients were divided into 2 groups based on the presence (n = 36) or absence (n = 363) of chylous ascites. RESULTS: Among the 399 patients, 36 (9%) developed chylous ascites. The median time to onset was 4 days (range, 2-7 days). The analysis of the various features of lymphadenectomy showed that the number of para-aortic lymph nodes (PALNs) removed was significantly greater in the patients with chylous ascites (p < 0.001). A cut-off value of >14 PALNs was a good predictor of chylous ascites. In all patients, chylous ascites resolved with conservative management. CONCLUSIONS: Postoperative chylous ascites was strongly associated with the number of harvested PALNs. According to our findings, we suggest that conservative treatment should be the first step in managing patients with chylous ascites. Using an abdominal drain after surgery seems to be an effective diagnostic tool and treatment method for chylous ascites.

Chylous ascites after laparoscopic donor nephrectomy.

INTRODUCTION: The aim of this study was to determine the incidence, presentation, management, and outcomes of chylous ascites following laparoscopic donor nephrectomy. METHODS: An Internet-based, multi-institutional survey was performed using http://www.surveymonkey.com. An email invitation to the voluntary survey was sent to 30 transplant centers and posted on CenterSpan, an email forum for transplant surgeons. The number of living donor transplantations and the number of cases of chylous ascites with clinical information, treatment and outcomes were sought from the questionnaire. RESULTS: A total of 12 centers responded and reported 7683 cases of live donor nephrectomy. The reported incidence of postoperative chylous ascites was 0.013% (n = 12). Six centers reported 10 cases of chylous ascites following laparoscopic donor nephrectomy and 2 cases after open donor nephrectomy. Among the eight patients who developed chylous ascites following laparoscopic donor nephrectomy, presentation was typically 2 weeks after the date of initial surgery. Conservative therapy was successful in 50% of cases. Refractory ascites managed secondarily with surgical intervention had a success rate of 100%. CONCLUSION: Chylous ascites is a rare complication following laparoscopic donor nephrectomy. Initial treatment should be conservative, with surgical therapy reserved for refractory cases.

Early enteral nutrition with polymeric feeds was associated with chylous ascites in patients with severe acute pancreatitis.

OBJECTIVE: Chylous ascites (CA) may be involved in the pathological process of severe acute pancreatitis (SAP), but the underlying mechanisms remain unknown. This study investigated the incidence of CA in patients with SAP and its relationship with enteral nutrition (EN). METHODS: A retrospective review of 85 patients with SAP admitted to our hospital was performed. Patients starting EN within 72 hours after the onset of SAP were classified as the early EN (EEN) group, and others, as the later EN group. The incidences of CA and prognosis in the EEN and later EN groups were examined with nutrition preparation of polymeric formula or semielemental feed. RESULTS: Thirteen (15.29%) of 85 patients were identified with CA. A higher incidence of CA was observed in EEN patients who received polymeric formula (9 of 33, P < 0.05). All patients with CA were successfully treated with a modified medium-chain triglyceride diet. Consequently, there were no differences in intensive care unit stay and in mortality rates in patients with or without CA. CONCLUSIONS: There was a higher incidence of CA associated with early enteral feeding of polymeric formula in patients with SAP. Future studies are warranted to confirm our findings and evaluate better enteral feeding options to avoid CA.

Chylous ascites as a complication of laparoscopic colorectal surgery.

INTRODUCTION: Until now, no data have been available on the incidence of chylous ascites after laparoscopic colorectal surgery. METHODS: From January 2007 to December 2011, 137 patients with colorectal cancer underwent laparoscopic surgery at our institution. The clinical data of the patients with postoperative chylous ascites were compared with those of the patients without chylous ascites. RESULTS: Chylous ascites developed in 9 of the 137 patients (6.5%). Blood loss, operative time, tumor location, and extent of lymph node dissection were not associated with postoperative chylous ascites. Mean postoperative hospital stay for patients with chylous ascites was significantly longer than that for patients without any complications (14 days vs 10 days; P < 0.001). Recurrence was observed in two of the nine patients with chylous ascites; it developed locally and in the liver in one patient, and peritoneal dissemination was seen in the other. The recurrence rate in the chylous ascites group (22.2%) was significantly higher than that in the non-chylous ascites group (3.9%; P = 0.016). The 3-year disease-free survival in the chylous ascites group (76.2%) was significantly lower than that in the non-chylous ascites group (93.4%; P = 0.020); however, the 3-year overall survival rates did not differ between the groups (87.5% vs 94.4%, respectively; P = 0.332). CONCLUSION: Chylous ascites are not a rare complication of laparoscopic colorectal surgery. It was managed conservatively in all cases but was associated with longer hospital stays. We recommend careful tissue dissection at a suitable plane and meticulous clipping during lymphadenectomy to prevent chyle leakage when lymphatic invasion is suspected.

Feasibility and safety of laparoscopic total proctocolectomy with ileal pouch-anal anastomosis for severe ulcerative colitis.

INTRODUCTION: The laparoscopic approach is accepted as a treatment option for patients with ulcerative colitis (UC) who are otherwise in good health. However, its application for patients with severe UC remains controversial. The purpose of this study was to evaluate the feasibility of the laparoscopic approach for severe UC cases. Short- and long-term clinical outcomes after laparoscopic total proctocolectomy with ileal pouch-anal anastomosis were compared between severe and mild-to-intermediate UC patients. METHODS: Cases treated between March 2002 and September 2010 were retrieved retrospectively from the database of Kyoto Medical Center and Kyoto University Hospital. Intraoperative complications and short- and long-term clinical outcomes were compared. RESULTS: A total of 31 patients underwent laparoscopic total proctocolectomy with ileal pouch-anal anastomosis. A comparison of short- and long-term clinical outcomes after one- or two-stage laparoscopic ileal pouch-anal anastomosis between severe (n = 7) and mild-to-intermediate (n = 21) UC patients revealed no significant differences. The proportion of patients with restoration of intestinal continuity did not differ between the groups (severe: 86%, mild to intermediate: 95%; P = 0.69). CONCLUSION: The present findings suggest that laparoscopic total proctocolectomy with ileal pouch-anal anastomosis for severe UC patients could be a good alternative approach when performed by an experienced hand.

Chylous ascites after liver transplantation: incidence and risk factors.

In this study, we evaluated the diagnosis, epidemiology, risk factors, and treatment of chylous ascites developing after liver transplantation (LT). Between 2002 and 2011, LT was performed 693 times in 631 patients at our clinic. One-hundred fifteen of these patients were excluded for reasons such as retransplantation, early postoperative mortality, and insufficient data. Chylous ascites developed after LT (mean ± SD = 8.0 ± 3.2 days, range = 5-17 days) in 24 of the 516 patients included in this study. Using univariate and multivariate analyses, we examined whether the following were risk factors for developing chylous ascites: age, sex, body mass index, graft-to-recipient weight ratio, Model for End-Stage Liver Disease score, vena cava cross-clamping time, total operation time, Child-Pugh classification, sodium level, portal vein thrombosis or ascites before transplantation, donor type, albumin level, and perihepatic dissection technique [LigaSure vessel sealing system (LVSS) versus conventional suture ligation]. According to a univariate analysis, a low albumin level (P = 0.04), the presence of ascites before transplantation (P = 0.03), and the use of LVSS for perihepatic dissection (P < 0.01) were risk factors for developing chylous ascites. According to a multivariate Cox proportional hazards model, the presence of pretransplant ascites [P = 0.04, hazard ratio (HR) = 2.8, 95% confidence interval (CI) = 1.1-13.5] and the use of LVSS for perihepatic dissection (P = 0.01, HR = 5.4, 95% CI = 1.5-34.4) were independent risk factors. In conclusion, the presence of preoperative ascites and the use of LVSS for perihepatic dissection are independent risk factors for the formation of chylous ascites. To our knowledge, this study is the most extensive examination of the development of chylous ascites. Nevertheless, our results should be supported by new prospective trials.

Postoperative chylous ascites after colorectal cancer surgery.

PURPOSE: To evaluate the diagnosis, epidemiology, risk factors, and treatment of chylous ascites after colorectal cancer surgery. METHODS: Among 907 patients who underwent colorectal cancer resection at our institution between 2006 and 2009, chylous ascites developed in 9. We analyzed the clinical data for these 9 patients. RESULTS: Five of the nine patients with chylous ascites had undergone right hemicolectomy and seven had undergone D3 lymph node dissection. In all patients, chylous ascites began to develop the day after commencement of oral intake or the next day. Two patients had no change in diet, one was started on a high-protein and low-fat diet, and six were put on intestinal fasting. Drainage tubes were removed within 5 days after treatment in seven patients. The hospital stay was about 2 weeks after surgery and 1 week after treatment. We found that the tumor area, tumors fed by the superior mesenteric artery, and D3 lymph node dissection were significantly associated with chylous ascites. CONCLUSIONS: Chylous ascites after colorectal cancer surgery occurred at an incidence of 1.0%, but was significantly more frequent after surgery for tumors fed by the superior mesenteric artery and after D3 lymph node dissection. Conservative treatment was effective in all cases.

Incidence, diagnosis, and treatment of chylous leakage after laparoscopic live donor nephrectomy.

BACKGROUND: Chylous leakage (CL) is a rare complication of laparoscopic live donor nephrectomy (LLDN). It may lead to malnutrition and immunological deficits because of protein and lymphocyte depletion. METHODS: Data from 208 consecutive LLDN performed at two institutions, between April 2000 and September 2010, were reviewed to identify the anatomical basis behind CL along with its diagnostic and therapeutic options. RESULTS: CL developed in eight donors (3.8%), as determined by high-volume drainage (range 540-800 mL/24 hr) of triglyceride-rich fluid. All donors were managed conservatively. Seven were put on total parenteral nutrition plus octreotide. One received low-fat diet, medium-chain triglyceride supplementation, and octreotide. Chylous fistulas resolved in 5 to 16 days (mean time 12.3 days). Drains were removed before hospital discharge, and no donor was readmitted and/or needed outpatient care. CONCLUSIONS: CL is a potentially insidious and perhaps misdiagnosed complication after LLDN. It occurs in nearly 4% of LLDN and it seems to be uniquely associated to left-sided kidney recovery because of distinctive lymphatics distribution around the periaortic area of dissection. Conservative therapy is effective in most donors and should be initially attempted. Surgical ligatures or fibrin sealants may be indicated in case of refractory CL before the arising of malnutrition and/or relevant immunodeficiency.

Postoperative chylous ascites in patients with gynecologic malignancies.

OBJECTIVE: To evaluate the incidence and the effective treatment of postoperative chylous ascites in patients with gynecologic malignancies. METHODS: In this report, we retrospectively reviewed the cases of 4119 patients who underwent pelvic and/or para-aortic lymph node dissection for gynecologic malignancies in Fudan University Cancer Hospital. RESULTS: Among these 4119 cases, 7 (0.17%) patients had chylous ascites postoperatively. The average age of these patients was 52 years. The mean time interval between operation and the appearance of chylous ascites was 30 days (range, 5-75 days). The incidence of chylous ascites after para-aortic lymphadenectomy was approximately 0.32% (5/1540), whereas the rate after pelvic lymphadenectomy alone was 0.077% (2/2579). All cases with chylous ascites were resolved by conservative treatment. This included placement of a peritoneal drainage tube. The mean time to resolution was 13 days (range, 2-28 days). None of the cases had recurrent chylous ascites during follow-up. CONCLUSIONS: Para-aortic lymph node dissection may be associated with postoperative chylous ascites. Patients may have their chylous ascites successfully treated with conservative management. An abdominal drainage tube can be a simple and effective approach and should be considered in the treatment.