First Case of Chylous Ascites after Laparoscopic Myomectomy: A Case Report with a Literature Review.

Introduction: Chylous ascites is a rare form of ascites characterized by milk-like peritoneal fluid, rich in triglycerides. Clinical signs and symptoms include abdominal distention, pain, nausea, and vomiting. In gynecology, the most common cause for its occurrence is lymph dissection leading to impairment of major lymphatic vessels. There are only a few reported cases of chylous ascites arising after operations for benign diseases. Case report: We report a case of a 46-year-old female patient, who underwent laparoscopy for a myomatous node with chylous ascites occurring on post-surgery Day 2. The ascites was conservatively managed. The exact cause of the chyloperitonitis could not be determined. Conclusion: Although extremely rarely, chylous ascites may also occur in operative interventions for benign diseases in gynecological surgery.

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.

Sirolimus Therapy for Patients With Lymphangioleiomyomatosis Leads to Loss of Chylous Ascites and Circulating LAM Cells.

A young woman received a diagnosis of abdominal, sporadic lymphangioleiomyomatosis (LAM) and multiple abdominal lymphangioleiomyomas and was referred for recurrent chylous ascites responding only to a fat-free diet. On admission, pulmonary function test (PFT) results showed a moderate reduction in the transfer factor for carbon monoxide with normal exercise performance. The serum vascular endothelial growth factor D (VEGF-D) level was 2,209 pg/mL. DNA sequences, amplified at loci kg8, D16S3395, D16S3024, D16S521, and D16S291 on chromosome 16p13.3, showed a loss of heterozygosity (LOH) only for kg8. Fat-free total parenteral nutrition in association with sirolimus (2 mg po daily) was initiated. Serum sirolimus levels were maintained at concentrations between 5 and 15 ng/mL. After 1 month, reintroduction of a low-fat oral feeding was achieved without recurrence of ascites. PFT results were stable. Interestingly, clinical improvement was associated with a reduction in the VEGF-D serum level (1,558 pg/mL). LOH at the kg8 biomarker in blood LAM cells was no longer detected.

Chylothorax and chylous ascites: management and pitfalls.

Leakage of lymph from the lymphatic ducts causes chylothorax (CT) or chylous ascitis (CA). This may happen for unknown reasons during fetal life or after birth and may also be caused by trauma after thoracic surgery or by other conditions. Fetal CT and CA may be lethal particularly in cases with fetal hydrops that sometimes benefit of intra-uterine instrumentation. After birth, symptoms are related to the amount of accumulated fluid. Sometimes, severe cardio-respiratory compromise prompts active therapy. Most patients with CT or CA benefit from observation, rest, and supportive measures alone. Drainage of the fluid may be necessary, but then loss of protein, fat, and lymphoid cells introduce new risks and require careful replacement. Low-fat diets with MCT and parenteral nutrition decrease fluid production while allowing adequate nutritional input. If lymph leakage does not stop, secretion inhibitors like somatostatin or octreotide are prescribed, although there is only weak evidence of their benefits. Imaging of the lymphatic system is indicated when the leaks persist, but this is technically demanding in children. Shunting of the lymph from one body space to another by means of valved catheters, embolization of the thoracic duct, and/or ligation of the major lymphatics may occasionally be indicated in cases refractory to all other treatments.

[Octreotide treatment for postoperative chylous ascites in an adult]. / Ascitis quilosa posquirúrgica en un adulto tratada con octreótida.

Chylous ascites is infequent after abdominal surgery. We describe the case of a 43-year-old man with portal cavernomatosis who underwent surgery to insert a splenorenal shunt, which was not placed due to the absence of signs of portal hypertension. On postoperative day 20, the patient developed abdominal distension and mild dyspnea and was diagnosed with chylous ascites, which was related to the surgery. The patient was initially treated with diet and diuretics, with no clinical response, and consequently octreotide therapy was started. Four days later, the ascites was almost resolved and an ultrasound scan at 4 months showed its complete disappearance. This article demonstrates the effectiveness of octreotide in the treatment of postsurgical chylous ascites.

[Chylous ascites after laparoscopic nephroureterectomy]. / Chylöser Aszites nach laparoskopischer Nephroureterektomie.

A 65-year-old man underwent a laparoscopic nephroureterectomy with a radical retroperitoneal lymphadenectomy for transitional cell carcinoma in the pyelon of the left kidney associated with a paraaortal lymphadenopathy. Four weeks later the patient presented with weight loss, a distended abdomen and a swelling of the left hemiscrotum. With increasing complaints and the suspicion of a large lymphocele an exploratory laparoscopy with the possibility of a fenestration was performed. Intraoperatively the laparoscopy revealed a chylous ascites but failed to detect an injury to the lymph system and a localised leak. The ascites eventually resolved under a strict dietary regimen with a medium-chain triglyceride-based diet and repeated long-term drainage. We report this case to encourage a multimodal approach in this potentially fatal complication.

[Postsurgical chylous ascites: case report and literature review]. / Tratamiento dietético de la ascitis quilosa postquirúrgica: caso clínico y revisión de la literatura.

Chylous ascites derives from chyle leakage into the peritoneal cavity, either due to rupture or obstruction of abdominal lymphatic vessels. The main clinical sign is abdominal distention, while diagnosis requires the presence of triglycerides in ascitic fluid. Neoplasms are the most common cause of chylous ascites, although less common causes, such as abdominal surgery, should also be considered. The mainstay of therapy is hyperproteic diet with fat restriction and middle-chain triglycerides. Parenteral nutrition is reserved for cases in which dietary treatment fails to restore an optimal nutritional status or is contraindicated, whereas surgery is considered for patients that are deemed refractory to conservative therapy. We present a case of chylous ascites secondary to retroperitoneal lymphadenectomy.

A respeito de um caso de quilotórax bilateral e quiloascite espontâneos: aspectos clínicos e cirúrgicos / About a case of espontaneous bilateral chylothorax and chyloascitis: clinical and surgical aspects

Efusão quilosa pleural ou quilotórax significa acúmulo quiloso no espaço pleural, geralmente como ruptura secundária dos ductos linfáticos torácicos, que pode ser promovida por vários estímulos, desde trauma, doenças malignas até causas idiopáticas. É definido como uma efusão de linfa na cavidade pleural, podendo ter origem no tórax ou na cavidade abdominal, ou em ambos. É de aspecto leitoso, inodoro, branco, de pH alcalino com gravidade específica acima de 1012, bacteriostático, não irritativo à pleura. É opalescente, formado quando triglicérides de cadeia longa da dieta são transformados em quilomícrons de baixa densidade lipoprotéica secretados no intestino. O quilo é transportado através do ducto torácico e drenado na veia subclávia esquerda. O diagnóstico é baseado em análise clínica da efusão pleural contendo quilomícrons e níveis de triglicérides maior que 110 mg/dL como indicativo praticamente certo de efusão pleural quilosa. A conduta depende da causa e das circunstâncias individuais. Um relato de quilotórax bilateral e quiloascite espontâneos é apresentado com ótima evolução através de tratamento conservador com a utilização de dieta enteral oligomérica, rica em aminoácidos, com glutamina e mínima oferta de triglicérides de cadeia média e octeotride

Chylous pleural effusion or chylothorax means chyle accumulation in the pleural space generally as a secondary disruption of thoracic lymphatics, that can be promoted by various stimulants, since trauma, malignancies, to idiopathic causes. Is defined as an effusion of limphin pleural cavity. Chyle may have its origin in the thorax or in the abdomen, or both. Is a milky, white, alkaline pH with a specific gravity above 1012, bacteriostatic and nonirritating to thepleural space, opalescent fluid formed when long-chain triglycerides in the diet are transformed into chylomicrons and very-low-density lipoproteins and secreted into intestinal lacteals. The chyle is transported through the thoracic duct and drained into the left subclavian vein. Diagnosis is based on a chemical analysis of the pleural effusion presenting chylomicrons, pleural triglyceride with levels greater than 110 mg/dL being nearly always indicative of a chylous pleural effusion. Management depends on the underlying cause and the individual circumstances. A case report of spontaneous chylothorax and chyloascitis is presented successfullytreated by conservative means, using oligomeric enteral feeding, rich in amino acids with minimum quantity of medium-chain-triglycerides, glutamine, and octeotride

A rare case of chylous ascites and chyluria in an adult nephrotic syndrome with focal segmental glomerulosclerosis.

The authors report the first case of chylous ascites and chyluria in a 65-year-old Thai women with nephrotic syndrome due to focal segmental glomerulosclerosis (FSGS), tip variant. She presented with generalized edema and abdominal discomfort. Abdominal paracentesis revealed milky white fluid. Chylous ascites was confirmed. Abdominal and thoracic computed tomography did not show any cause of chylous ascites and chyluruia. Lymphoscintigraphy could not demonstrate lymph flow obstruction and connection between lymphatic pathway and KUB system. Those could have explained the chylous ascites or chyluria. Hypoalbuminemia-induced bowel edema may predispose to change the permeability of mucosal or serosal lymphatics. This could result in chylous ascites but the cause of chyluria could not be determined in this case.

Use of orlistat (xenical) to treat chylous ascites.

Chylous ascites is uncommon and occurs in about 1 in 20,000 hospital admissions. Causes include disruption of the lymphatic system due to malignancy, cirrhosis, surgery, or radiation therapy. The mainstay of therapy has been low-fat diet supplemented with medium-chain triglyceride oil. However, dietary compliance can be difficult to achieve for adequate response. We report a 47-year-old man with hepatitis C and alcohol-related cirrhosis with new-onset chylous ascites and chylothorax. His ascites triglyceride was 585 mg/dL, and the pleural fluid triglyceride was 691 mg/dL. Ascitic and pleural fluid cytology and acid-fast bacilli stain were negative. The patient was treated with low-fat diet and medium-chain triglyceride oil. However, his ascites remained chylous after 1 week of treatment because of poor compliance with the dietary restrictions. Orlistat was then added to his treatment regimen. A half week later, the chylous component of his ascites resolved. Remaining high-volume clear ascites was treated with placement of a transjugular intrahepatic portosystemic shunt. To our knowledge, orlistat has never been used in the treatment of chylous ascites. This case suggests the potential value of adding orlistat to low-fat diet and medium-chain triglyceride oil in the treatment of chylous ascites, especially in patients who are unable to comply with the dietary restrictions.

Chylous ascites after laparoscopic donor nephrectomy.

Laparoscopic living-donor nephrectomy has decreased the disincentives to live renal donation with a risk of complications similar to that of open donor nephrectomy. We report a patient who developed chylous ascites after an otherwise-uneventful laparoscopic donor nephrectomy. On MEDLINE search, we could find only two other cases with similar complications. This condition has the potential to cause significant morbidity in the donor, which may reduce the advantages of the minimally invasive approach. We suggest that meticulous dissection of the renal hilum and clipping of lymphatic tissue around the renal vessels could prevent this untoward complication.

Chylous ascites: treated with total parenteral nutrition and somatostatin.

AIM: To determine the effects of total parenteral nutrition and somatostatin on patients with chylous ascites. METHODS: Five patients were diagnosed with chylous ascites on the basis of laboratory findings of ascites sample from Nov 1999 to May 2003. Total parenteral nutrition and somatostatin or its analogue was administered to 4 patients, while the other one only received total parenteral nutrition. All the patients had persistent peritoneal drainage, with the quantity and quality of drainage fluid observed daily. Necessary supportive treatments were given to the patients individually during the therapy. RESULTS: Two of 4 patients who received somatostatin therapy obtained complete recovery within 10 d without any recurrence while on a normal diet. In these 2 patients, the peritoneal drainage reduced to zero in one and the other's decreased from 2,000 mL to 80 mL with a clear appearance and negative qualitative analysis of chyle. Recurrent chylous ascites, though relieved effectively by the same method every time, developed in one patient with advanced pancreatic cancer. The other patient's lymphatic fistula was blocked with the fibrin glue after conservative treatment. The patient who only received total parenteral nutrition was cured 24 d after therapy. CONCLUSION: Total parenteral nutrition along with somatostatin can relieve the symptoms and close the fistula in patients with chylous ascites rapidly. It appears to be an effective therapy available for the treatment of chylous ascites caused by various disorders.

Postmenarchal development of chylous ascites in acrocephalosyndactyly with congenital lymphatic dysplasia.

BACKGROUND: Acrocephalosyndactyly is a syndrome characterized by congenital malformation of the skull with craniosynostosis, midface hypoplasia, and symmetrical webbed fusion of the fingers and toes. We describe a possible pathophysiologic mechanism for chylous ascites that developed several months after menarche in a woman with acrocephalosyndactyly and congenital lymphatic dysplasia. CASE: A 25-year-old nulligravid woman with acrocephalosyndactyly, at 18 months after menarche, developed persistent abdominal distension at age 18 years. Laparoscopy at age 25 years revealed chylous ascites with marked chronic peritoneal inflammation, and lymphatic dysplasia with lymphocysts. With hormone manipulation, the chylous ascites fluctuated. CONCLUSION: After menarche in a woman with acrocephalosyndactyly, ovarian steroid hormones might have increased lymph production and hydrostatic pressure, causing rupture of congenitally dysplastic lymph vessels resulting in chylous ascites.

Management of chylous ascites following laparoscopic presacral neurectomy.

Chylous ascites is an extremely rare complication of laparoscopic presacral neurectomy (LPSN), and treatment is still controversial. Four patients undergoing LPSN for dysmenorrhoea or chronic pelvic pain were complicated with chylous ascites. Two were successfully treated with bipolar cauterization and one, after the failure of initial treatment by bipolar cauterization, was then effectively managed by compression with Gelform and closure of the peritoneum of the presacral area by suture through laparoscopy. The fourth patient had persistent chyle leakage from the drainage tube after electrocauterization and was finally cured by conservative management including removal of the drainage tube and a low-fat diet for 3 weeks. Chylous ascites has not been reported in laparoscopic presacral neurectomy. Management that is quick, effective and subjects the patients to the least amount of suffering is still unresolved. Repeated laparoscopy can be considered to identify the possibility of injury to lymphatic vessels, to relieve abdominal distention due to chyle accumulation, and to apply electrocauterization or compression with Gelform and closure of the peritoneum. Conservative treatment with a low-fat diet may need a longer time. The use of a drainage tube may provide negative pressure allowing a continuous leakage of chyle. However, more controlled study is required to identify the most proper and effective management.

A case of the yellow nail syndrome associated with massive chylous ascites, pleural and pericardial effusions.

A 26-year-old male patient with a history of chronic peripheral lymphedema, yellowish coloured slow growing nails and pleural effusions since early childhood is described. After 23 years he developed a chylous ascites and scintigraphy with technetium-99m labeled albumin clearly demonstrated a diffuse protein loss involving the whole jejunum and ileum. Subsequent jejunal and duodenal biopsies showed the typical histological findings of intestinal lymphangiectasia thereby confirming a diffuse intestinal lymphatic damage. In addition to the gastrointestional symptoms the patient developed a pericardial effusion diagnosed by echocardiographic imaging. Dietary treatment with middle chained triglycerides and intravenous human albumin supplementation was followed by the reduction of the ascites and improvement of the peripheral lymphedema. To our knowledge this is the first description of the yellow nail syndrome associated with a diffuse lymphangiectasia involving the whole small bowel.

Management of chyloperitoneum after abdominal aortic surgery.

Chyloperitoneum is a rarely reported complication of abdominal aortic surgery. From 1981 to 1992, we treated 5 cases of chylous ascites after operations on the abdominal aorta and reviewed 22 previously published cases. There were 22 men and 5 women, with a mean age of 63.8 years (range: 27 to 93 years). Twenty cases (74.7%) occurred after abdominal aortic aneurysm resection, 5 (18.5%) after aorto-femoral bypass for occlusive disease, and 2 (6.8%) after resection of infected aortic grafts, 1 for occlusive disease and the other for infrarenal aortic aneurysm. Abdominal distention was the most common presenting symptom, occurring in 26 (96.3%) of 27 patients. The mean time from aortic operation to the development of symptoms was 18.5 days (range: 7 to 120 days). Diagnosis was confirmed by paracentesis, which yielded lipemic, sterile fluid in all patients. Therapeutic paracentesis was not successful when used alone, but, when combined with a medium-chain triglyceride (MCT) diet or total parenteral nutrition (TPN), it resulted in resolution of chyloperitoneum in 8 of 14 patients (57.2%). TPN alone or with paracenteses and/or diuretics was successful in 9 of 15 (60%) patients. Peritoneovenous shunts resolved chylous ascites in four of five patients not responding to diet and/or TPN but resulted in one death due to sepsis. Operative ligation of the injured lymphatic channel was successful in all five patients treated by laparotomy when nonoperative efforts failed. Chyloperitoneum resolved in all but two (7.7%) patients. There were five (18.5%) deaths, but only three (11.5%) were directly related to chylous ascites. Treatment with TPN resolved chyloperitoneum in all five of our own patients. We reached the following conclusions: (1) Chyloperitoneum is a rare complication of aortic surgery; (2) This disorder should be considered whenever persistent abdominal distention appears after aortic surgery; (3) The diagnosis is easily confirmed by paracentesis; and (4) Surgery to close the lymph fistula should be reserved for those patients in whom conservative therapy with MCT diets or TPN has failed.