Successful Treatment of Cirrhotic Chylous Ascites using Orlistat and Dietary Modifications: A Case Study and Literature Review.

BACKGROUND Chylous ascites (chyloperitoneum), a condition arising from lymphatic leakage in the peritoneal cavity, is rare in liver cirrhosis patients, accounting for less than 1% of cases. Treatment typically involves therapeutic paracentesis, dietary modifications, a low-fat, high-protein diet, and medium-chain triglyceride (MCT) supplementation. Orlistat, a fat absorption inhibitor, has been reported to show potential efficacy in treating chylous ascites. CASE REPORT We detail the case of a 59-year-old male patient admitted for decompensated liver disease and worsening ascites. Diagnostic paracentesis identified chylous ascites, indicated by a 3.5 mmol/L triglyceride level. Despite administering therapeutic paracentesis, dietary modifications, MCT supplementation, Spironolactone, and Terlipressin for a presumed hepatorenal syndrome, the patient's ascites remained chylous for two weeks. On administering orlistat, a significant reduction in ascites volume and chylous content was observed, with triglyceride levels dropping to 0.7 mmol/L. CONCLUSIONS Our case illustrates the potential of orlistat in managing chylous ascites in liver cirrhosis patients, marking only the second such case reported in the existing literature. It encourages further exploration of orlistat's therapeutic potential in treating chylous ascites.

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.

Conservative management of chylous ascites after oncological surgery for peripheral neuroblastic tumors in pediatric patients.

Chylous ascites may complicate the postoperative course of abdominal surgery mainly due to the iatrogenic disruption of the lymphatic channels during extensive retroperitoneal dissection. Sparse data are available regarding treatment; however, in many cases a recommended first-line treatment approach is by way of enteral feeding, consisting of a formula high in medium-chain triglycerides (MCTs) together with a complete total parenteral nutrition teamed with somatostatin (or an equivalent). Nonetheless, the ligation of chylous fistulae, together with the application of Fibrin glue, as well as the creation of peritoneal-venous shunts have also been documented. The aims of this study are to document incidence of postoperative chylous ascites following resection of abdominal peripheral neuroblastic tumors, evaluate efficacy of the management of chylous ascites, and investigate the main risk factors. A survey was carried out over a span of six years, from March 2010 to March 2016 at Giannina Gaslini Children's Hospital involving seventy-seven children with resections of peripheral neuroblastic tumors. Incidence rate of postoperative chylous ascites following a normal diet was 9% (n=7). Treatment using total parenteral nutrition with octreotide resulted in a complete recovery from chylous ascites within a 20 day period without recurrence. Length of operative time, nephrectomy, and the extension of lymphadenectomy were all significantly associated with a higher incidence of postoperative chylous ascites (p<0.05) which also lengthened hospital stay (p<0.05) and possibly delayed beginning adjuvant chemotherapy.

Ascitis quilosa postraumática tratada con nutrición parenteral total y octreótido / Post-trauma Chylous Ascites Treated with Total Parenteral Nutrition and Octreotide

La ascitis quilosa es la acumulación de quilo en la cavidad peritoneal por ruptura u obstrucción de los conductos linfáticos abdominales. Aunque es infrecuente, se describe mayor probabilidad de aparición después de traumas abdominales. Se presenta un paciente masculino de 46 años que sufre herida por arma blanca tóracoabdominal por lo que requirió tratamiento quirúrgico de urgencia. Luego de varias cirugías se constató la presencia de líquido abdominal blanquecino, con triglicéridos elevados. Se confirmó la ascitis quilosa, que se reabsorbió en 45 días con nutrición parenteral y octreótido(AU)

Chylous ascites is the accumulation of lipid-rich lymph in the peritoneal cavity due to rupture or obstruction of the abdominal lymph ducts. Although it is rare, greater probability is described for its onset after abdominal traumas. The case is presented of a 46-year-old male patient who suffers from a thorax-abdomen knife wound and therefore required emergency surgical treatment. After several surgeries, the presence of whitish abdominal liquid was detected, with elevated triglycerides. Chylous ascites was confirmed, which was reabsorbed in 45 days with parenteral nutrition and octreotide(AU)

Ascitis quilosa postraumática tratada con nutrición parenteral total y octreótido / Post-trauma Chylous Ascites Treated with Total Parenteral Nutrition and Octreotide

La ascitis quilosa es la acumulación de quilo en la cavidad peritoneal por ruptura u obstrucción de los conductos linfáticos abdominales. Aunque es infrecuente, se describe mayor probabilidad de aparición después de traumas abdominales. Se presenta un paciente masculino de 46 años que sufre herida por arma blanca tóracoabdominal por lo que requirió tratamiento quirúrgico de urgencia. Luego de varias cirugías se constató la presencia de líquido abdominal blanquecino, con triglicéridos elevados. Se confirmó la ascitis quilosa, que se reabsorbió en 45 días con nutrición parenteral y octreótido(AU)

Chylous ascites is the accumulation of lipid-rich lymph in the peritoneal cavity due to rupture or obstruction of the abdominal lymph ducts. Although it is rare, greater probability is described for its onset after abdominal traumas. The case is presented of a 46-year-old male patient who suffers from a thorax-abdomen knife wound and therefore required emergency surgical treatment. After several surgeries, the presence of whitish abdominal liquid was detected, with elevated triglycerides. Chylous ascites was confirmed, which was reabsorbed in 45 days with parenteral nutrition and octreotide(AU)

Successful management of chylous ascites: A report of two cases.

Chylous ascites consists of the accumulation of chyle in the peritoneal cavity. Diagnosis is established by cytochemical analysis of the fluid revealing fat globules and high triglyceride content. The majority of cases are caused by pathology that interferes with abdominal retroperitoneal lymphatic drainage. We present two cases of postoperative chylous ascites, one following a bilateral nephrectomy, the other following orthotopic heart transplantation. Treatment is typically conservative with the aim to alleviate abdominal distension and reduce the flow of lymph into the mesenteric lymph nodes. Postsurgical chylous ascites has high cure rate with conservative therapy alone. Therapeutic paracentesis, diuretics, salt restriction, a high-protein, low-fat, mediumchain triglyceride diet, and parenteral nutrition are considered in chronic cases. The effects of longterm paracentesis on patients remains to be seen. In patients requiring renal replacement therapy, removal of chyle during peritoneal dialysis is often attempted.

Chylous ascites after liver transplant: case report and review of literature.

CASE: A 62-year-old man with cirrhosis, hepatitis C, and hepatocellular carcinoma, underwent a liver transplant. On day 11 after surgery, a chylous leak from a partial wound dehiscence was noted. The leak did not respond to 2 weeks of uninterrupted, fat-free clear liquid diet and 12-hour total parenteral nutrition at night. The same treatment was continued for another 6 weeks with fatty meal challenge every weekend, which he failed. He was then given a fat-free clear liquid diet, 24-hour total parenteral nutrition, and octreotide 100 µg subcutaneously every 8 hours for 14 days. A prompt response was noted. His recovery was excellent at the time of this writing (9 months' follow-up). DISCUSSION: Eleven major cases have been reported with 9 cases being managed conservatively. Four were given a diet plus total parenteral nutrition without octreotide producing a cure in 3 to 36 days. Two cases (including ours) were given the diet and total parenteral nutrition, which failed; octreotide was then added, and these cases were cured in 2 to 4 weeks. Therefore, diet with total parenteral nutrition failed in 33.3% of the cases (2/6). In 3 cases, octreotide was used from the outset. They were all cured in ≤ 2 weeks. One case was operated on for peritonitis; chylous ascites was found and a leak was ligated. One patient with congenital lymphatic disorder underwent peritoneovenous shunting. Octreotide was not used in any of the cases of chylous ascites that were treated surgically. CONCLUSIONS: If exploratory surgery is done for any other reason, it is best to identify a chylous leak and ligate it. Otherwise, we recommend octreotide combined with a fat-free, clear liquid diet, and supplementation with medium chain triglycerides and total parenteral nutrition from the outset.

Successful management of congenital chylous ascites with early octreotide and total parenteral nutrition in a newborn.

Congenital chylous ascites (CCA) is a rare disease that results from maldevelopment of the intra-abdominal lymphatic system. Few cases have been described and no gold standard treatment has been defined so far. Octreotide, a somatostatin analogue, has been used for the treatment of CCA, but always after a failed conservative approach with fasting, total parenteral nutrition (TPN) or medium chain triglyceride (MCT) feeds. We report the case of a newborn with CCA treated by fasting, TPN and octreotide for a period of 15 days until the abdominal distension was successfully reduced at which point treatment was switched to an MCT formula. On day 25 the patient was breastfed and was discharged on day 33. No recurrence of chylous ascites was noted. Our experience highlights the successful treatment with TPN and octreotide as the first step for the conservative approach of CCA in a newborn, reducing the length of treatment and hospitalisation.

[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.

[Dietary treatment of patients with lymphangiomyoma]. / Diaetbehandling af patient med lymfangiomyom.

A case of lymphangiomyoma, manifested by chylous ascites, in a 32 year-old woman is presented. Treatment with dietary fat restriction supplemented with medium chain triglycerides was successful, and the patient has remained free from chylous effusions for nearly two years.

Chylous ascites: a sequel of pelvic radiation therapy.

Chylous ascites is an unusual condition with many causes. Two cases are presented in which it appeared to be related to whole pelvis irradiation in one patient for carcinoma of the vagina and in another for carcinoma of the vulva. The diagnosis is made by paracentesis and analysis of the fluid. The underlying disease usually requires identification by exploratory laparotomy. Although a malignant process is the most common cause, the only findings in the authors' cases were widespread radiation changes in the intestine. After diagnosis treatment by low-fat diet with medium-chain triglyceride supplements resulted in disappearance of chylous ascites.