Summary: Background. Chyloperitoneum is a rare postoperative complication that might be caused by an interruption of chylous ducts in the mesenteric root or the cysterna chyli. Two cases of chyloperitoneum after duodenopancreatectomy are reported in the literature. Methods. We here report the third case that developed a chyloperitoneum 2 wk postoperatively when he resumed his normal diet. Results. The patient was treated conservatively with paracenteses and chyloperitoneum subsided thereafter. Conclusions. Chyloperitoneum after extended duodenopancreatectomy might be treated conservativel

Büchler, Markus

Kollmar, Otto

Schilling, Martin

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Treatment of Chyloperitoneum After Extended Lymphatic Dissection During DuodenopancreatectomyOtto Kollmar, Martin K. Schilling,* and Markus W. BüchlerDepartment for Visceral and Transplant Surgery, University of Bern, Inselspital, Bern, SwitzerlandSummaryBackground. Chyloperitoneum is a rare postoperative complication that might be caused by an inter-ruption of chylous ducts in the mesenteric root or the cysterna chyli. Two cases of chyloperitoneum afterduodenopancreatectomy are reported in the literature.Methods. We here report the third case that developed a chyloperitoneum 2 wk postoperatively when heresumed his normal diet.Results. The patient was treated conservatively with paracenteses and chyloperitoneum subsided thereafter.Conclusions. Chyloperitoneum after extended duodenopancreatectomy might be treated conservatively.Key Words: Chyloperitoneum; duodenopancreatectomy; conservative treatment.IntroductionChyloperitoneum is a rare complication causedby an obstruction or interruption of chylous ductsand cysts in the mesenteric root, the cysterna chyli,or the thoracic duct. The most common etiologicalfactors are primary lymphatic dysplasia (1), infec-tions, like filiariasis and tuberculosis, neoplasmsinvading or compressing the lymphatic ducts, andsurgery or radiation (2). Here the extensive loss oflymph nodes and collecting channels causes con-gestion of upstream lymph ducts. Lymphoductularregeneration proceeds by vascular budding or sprout-ing, thus leading to collateral lymph flow. Interest-ingly, lymphatic vessels do not regenerate whennode-bearing areas are destroyed by radiation orexcised surgically (3). It has been shown that lymphcysts may occur after single lymph node biopsies orremoval of a large amount of connective tissue sur-rounding lymph nodes. Most of these lymph cystsremain asymptomatic. On rare occasions they mayenlarge and compress adjacent structures, thus caus-ing pain and bowel obstruction. Lymph cysts andchylous ascites following abdominal surgery are rarecomplications, but have been reported after variousprocedures, including abdominal aortic surgeryInternational Journal of Pancreatology, vol. 27, no. 1, 83–87, February 2000© Copyright 2000 by Humana Press Inc.All rights of any nature whatsoever reserved.0169-4197/00/27:83–87/$11.2583Case Report*Author to whom all correspondence and reprint requestsshould be addressed: Department for Visceral- and TransplantSurgery, University of Bern, Inselspital, 3010 Bern, Switzer-land. E-mail martin.schilling@insel.ch84 Kollmar, Schilling, and BüchlerInternational Journal of Pancreatology Volume 27, 2000(4–7), spinal surgery (8), nephrectomy (9), or dis-section for testicular cancer (10), with interruptionof retroperitoneal or mesenteric lymph structuresbeing the common denominator (4,8,12–16). Mostreports are anecdotal and hospital records list theincidence of diagnosis as 1 out of 100,000 admis-sion (11). Chylous ascites after duodenopancreati-cotectomy has only been reported twice (17,18). Thisis the third patient reported in the literature, whodeveloped a chyloperitoneum after extended lym-phatic dissection during duodenopancreatectomy.Case PresentationA 75-yr-old male with an uneventful medical his-tory was admitted after a single episode of acute epi-gastric pain. He also complained of acholic stoolsand dark brown urine. Physical examination revealedjaundiced sclera and integument and a localized ten-derness in the upper abdomen. Pathological labora-tory values included: bilirubin 179.7 µmol/L (normalvalues <18.8 µmol/L), bilirubin direct 136.6 µmol/L(<5.1 µmol/L), ASAT 177 U/L (10–50 U/L), ALAT298 U/L (10–50 U/L), γ-GT 100 U/L (11–64 U/L),and AP 607 U/L (56–119 U/L).Abdominal ultrasound as well as CT and MRIshowed a dilatation of the intra-and extrahepatic bileducts and a tumorous mass in the distal choledochusduct, suspicious of distal cholangiocarcinoma. Ahigh-grade stenosis in the distal choledochal ductand a normal pancreatic duct was found on ERCP.After papillotomy and stent implantation the patientwas scheduled for surgery.Surgery and Postoperative CourseAn extended pylorus preserved duodenopancre-atectomy with lymph dissection in the hepatoduo-denal ligament, interaortocaval (Fig. 1) and aroundthe SMA and TCA was performed. The patient wasextubated postoperatively.From the end of operation until the next morning,300 mL of clear fluid drained through two easy-flowdrainages placed at the pancreatic and biliary anas-tomosis. During the next 24 h a total of 100 mL fluiddrained through the easy-flow drainages and thedrains were removed thereafter.Enteral feeding through a jejunal feeding tube wasstarted on postoperative d (POD) 1, until POD 5,when oral feeding was started. A gastric emptyingdelay protracted oral feeding for 2 d. The coursethereafter was uneventful and the patient was dis-charged on POD 16.Histologically a poorly differentiated, mainlysolid and partly dissociative growing adenocarci-noma with neuroendocrine differentiation was found.Four out of 11 lymph nodes from the interaortocavalregion contained metastasis. Interestingly, the restof the lymphatic tissue, including peripancreaticlymph nodes, were without metastases. Neoplasticcells were mainly localized on the wall of the distalcholedochal duct but not in the periductal zone. Thecarcinoma was classified as choledochal duct ade-nocarcinoma (T2, N2, M0).Second AdmissionFive days after discharge the patient was read-mitted with abdominal distension and coprostasis.He complained of abdominal discomfort and pain.On physical examination we saw a distressed patientwith a distended abdomen and guarding on palpa-tion but no peritoneal signs. Bowel sounds werenormal and laboratory values, including electrolytes,hemoglobin, leukocytes, amylase, alcaline phos-phatase,ALAT,ASAT, and γ-GT, were within normallimits. An abdominal X-ray showed coprostasis inthe ascending colon, no fluid levels, or free air. Tho-racoabdominal CT scan showed pleural effusions,pulmonary atelectasis, and free fluid in the abdomenwithout signs of bowel or biliary obstruction. A para-centesis was performed and 3 and 5 L of chylousfluid were removed respectively, after which theascites subsided.Laboratory values of the opaque peritoneal fluidwere: sodium 132 mmol/L, potassium 4.3 mmol/L,pH 7.6, glucose 8.32 mmol/L, protein 33.3 g/L, cho-lesterol 1.52 mmol/L, triglyceride 0.99 mmol/L,LDH 207 U/L, lipase 22 U/L, α-amylase 18 U/L. Acell count was performed that revealed cell number767 × 106/L (normal 0–4 × 106/L), mononuclear cells96%, polynuclear cells 4%, erythrocytes 1510 ×106/L. In oil-red staining no extracellular fat was vis-ible. Immunohistochemically a significant expres-sion of CD-45 was visible. The T-cell/B-cell quotientwas 51. These cytological examinations were sus-picious for chyloperitoneum; however, chemicallyno significant cholesterol [58.77 mg/dL] and triglyc-eride [86.62 mg/dL] values were found.Treatment of Chyloperitoneum 85International Journal of Pancreatology Volume 27, 2000After the two paracenteses the patient improvedclinically and maintained a stable weight. The patientwas discharged 1 wk after admission and continuesto do well 3 mo postoperatively.DiscussionLymphatic capillaries collect and transport intesti-nal interstitial tissue fluid to valved collecting ves-sels. Interposed lymph nodes act as mechanical andimmunological filters before emptying the lymphinto the cysterna chyli intra-abdominally and finallyinto the bloodstream. The cysterna chyli is locatedon the anterior aspect of L 1/2 at the same level as thepancreatic head. It is located on the right side of theaorta, where interaortocaval lymph nodes ought tobe dissected for lymphadenectomy during extendedduodenopancreatectomy. Many distinct anatomicvariants of the abdominal lymphatic plexus and thecysterna chyli are described that might render somepatients at risk to develop chylous fistulae afterextended interaortocaval lymphadenectomy (19).Postoperative chylous ascites most often devel-ops through fistulae between intestinal lymphaticsor the cysterna chyli and the peritoneal cavity (20).Although small lymph leaks are commonly seenintraoperatively (21) they rarely cause chyloperi-toneum, because of extensive collateral lymph chan-nels (20), or they remain asymptomatic and aretherefore not recognized clinically.Naturally, the risk of lymphatic leak is higher withextensive surgery, especially when a thorough intera-ortocaval lymphadenectomy is carried out, as in the case presented here. Noteworthy was the latedevelopment of chylous ascites, approx 2 wk afterduodenopancreatectomy. Experimental studiesdemonstrate that flow-through lymphatic channelsin the fasting state is <1 mL/kg/h but can increaseto 225 mL/kg/h after a fatty meal (20,22), whichmight have been the case in our patient, who was ona restricted low-fat diet during this hospital stay, butresumed his normal diet after his discharge.The diagnosis of chyloperitoneum is establishedby laboratory analysis of a chylous sample with cho-lesterol, triglyceride, and analysis of lipoprotein profiles being suggestive of chyloperitoneum.Triglyceride has been analyzed most extensively andvalues >110 mg/dL are highly suggestive of a chy-lous effusion (23). Treatment is imperative whenpatients develop respiratory symptoms or lose exces-sive amounts of fluid, protein, fats, vitamin K, andimmunoregulatory lymphocytes (21). Those lossesrender patients susceptible to infections resultingfrom T-cell depletion (24).Although some advocate early reoperation withfistula occlusion (after intraoperative localization ofthe fistula by feeding high-fat oral diets preopera-tively) or by shunting the peritoneal cavity to thevenous system (25), conservative management is theprimary treatment and sometimes the only measurerequired (26). It consists of fat or medium-chaintriglyceride-free diets and substitution with high protein contents or total parenteral nutrition. Theformation of intestinal lymph and lymph flow is thusdecreased to a minimum, which allows the fistulasto heal and close and the collaterals to open up(27,28). Treated that way, lymphatic leaks often heal spontaneously over the course of 1–2 wk underthose conservative measures (18), which was thecase in our patient, as well as in most other patientsreported in the literature (Table 1). Adjunct mea-sures like repeated complete paracentesis are effec-tive for symptomatic relief, especially in dyspnoeicpatients (20).Fig. 1Fig. 1. Postoperative situs after interaortocaval lym-phadenectomy. The cysterna chyli is usually located atthe right side of the aorta (indicated by the arrow) whereinteraortocaval lymphadenectomy ought to be performed.86 Kollmar, Schilling, and BüchlerInternational Journal of Pancreatology Volume 27, 2000Table 1Chyloperitoneum: Comparison of Cases in the Literature Including the Authors’ CasesReference Cases Operative procedure Treatment OutcomeWalker WM et al. (17) 1 Pancreatoduodenectomy Paracentesis and diet → Resolvedreoperation (small bowelobstruction)Fleisher HL et al. (25) 1 Abdominal aortic aneurysm resection P-V shunt Resolved in 4 wkAblan CJ et al. (15) 4 2× abdominal aortic aneurysm resection, 3× diet, 1× P-V shunt 3× resolved,1× colon resection, 1× mesovaval 1× deathshunt procedurePabst TS et al. (4) 27 3× abdominal aortic aneurysm resection, 5× TPN Resolved2× resection of infected aortic grafts 5× operative ligation, 5× P-V all of 5(own cases) 22× abdominal aortic surgery shunt, 4× TPN and diet, 8× 20 of 22(previously published cases) only paracentesis and diet casesBaniel J et al. (10) 18 Retroperitoneal lymph node dissection 10× TPN, 1× paracentesis, Resolved infor testicular cancer 5× total parenteral 2–12 wkhyperalimentation, 2×LeVeen shuntDeHart MM et al. (8) 3 Anterior spinal procedures Retroperitoneal drains ResolvedGeisler JP et al. (14) 2 Retroperitoneal lymph node dissection (1) Diet, hyperalimentation (1) Recurrencefor endometrial (1) and fallopian tube and paracentesis of chylous(2) cancer (2) Paracentesis and diet ascites(2) ResolvedPanieri E et al. (6) 1 Abdominal aortic aneurysm resection Paracentesis and diet Resolved in 5 wkHalloul Z et al. (7) 1 Ruptured infrarenal aortic aneurysm 3 wk paracentesis and Resolved indiet → surgery → 5 wk TPN 12 wkHalachmi S et al. (13) 1 Retroperitoneal lymph node dissection Reoperation (abdominal Resolvedfor testicular tumor drain) and then dietMladinic-Vulic D 1 Nephrectomy Diet Resolvedet al. (9) in 2wkGaglio PJ et al. (16) 2 Orthotopic liver transplantation Paracentesis, TPN ResolvedBauwens K et al. (26) 1 Abdomino-thoracic esophageal resection 2 wk TPN, than Resolvedreoperation and ligaturePetrasek AJ et al. (20) 1 Right-to-left femorofemoral bypass Paracentesis and TPN Resolvedin 1 wkCope C et al. (18) 2 Bowel obstruction post Whipple procedure (1) 2× PTCLD, P-V shunt (1) Resolvedand abdominal aortic aneurysm resection (2)Haberal M et al. (12) 1 Partial liver transplantation Reoperation ResolvedChen FP et al. (21) 4 Laparoscopic presacral neurectomy 2× laparoscopic cauterization, Resolved1× laparoscopy twiceand suture, 1× laparoscopyand dietMuller S et al. (5) 1 Abdominal aortic aneurysm resection 12 wk TPN → 12 wk diet ResolvedKolmar 1 Duodenopancreatectomy Paracentesis Resolvedin 1 wkaTPN = total parenteral nutrition, diet = low-fat diet, P-V shunt = peritoneovenous shunt, PTCLD = percutaneous transabdominalcatheterization of the lymphatic ducts.Treatment of Chyloperitoneum 87International Journal of Pancreatology Volume 27, 2000AcknowledgmentThe excellent secretarial assistance of SandraNowak is gratefully acknowledged.References1 Bappal B, Ghani SA, Chaudhary R, Vaishnav A. Successfulsurgical treatment of congenital chylous ascites. Indian Pedi-atr 1998; 35: 276,277.2 Browse NL, Wilson NM, Russo F, Al-Hassan H, Allen DR.Aetiology and treatment of chylous ascites. Br J Surg 1992;79: 1145–1150.3 DePalma RG. (1991) Disorders of the lymphatic system. InTextbook of surgery: the biological basis of modern surgi-cal practice, Sabiston DC ed. Saunders, Philadelphia pp.1479–1489.4 Pabst ST, McIntyre KE, Schilling JD, Hunter GC, BernhardVM. Management of chyloperitoneum after abdominal aorticsurgery. Am J Surg 1993; 166: 194–198.5 Muller S, Lees T. Chyloperitoneum—an infrequent com-plication of abdominal aortic aneurysm repair. Eur J VascEndovasc Surg 1998; 16: 443, 444.6 Panieri E, Kussman BD, Michell WL,Tunnicliffe JA, Immel-man EJ. Chylous ascites following abdominal aortic surgery.S Afr J Surg 1995; 33: 26–28.7 Halloul Z, Meyer F, Bürger T, Lippert H. Chylous ascites,a rare complication of aortic surgery. Vasa 1995; 24: 377–381.8 DeHart MM, Lauerman WC, Conely AH, Roettger RH,WestJL, Cain JE. Management of retroperitoneal chylous leak-age. Spine 1994; 19: 716–718.9 Mladinic-Vulic D, Krzelj V, Balarin L, Saraga M, BudimirD, Vukic Z, Gabric K. Postoperative chylous ascites. ActaPaediatr 1995; 84: 949–951.10 Baniel J, Foster RS, Rowland RG, Bihrle R, Donohue JP.Management of chylous ascites after retroperitoneal lymphnode dissection for testicular cancer. J Urol 1993; 150:1422–1424.11 Silk Yn, Goumas WM, Douglass HO, Huben RP. Chylousascites and lymphocyst management by peritoneovenousshunt. Surgery 1991; 110: 561–565.12 Haberal M, Karakayali H, Moray G, Bilgin N. Surgical treat-ment of chylous ascites following partial living-related livertransplantation. Transpl Int 1998; 11: 327,328.13 Halachmi S, Noyman A, Moskovitz B, Nativ O. Successfultreatment of postretroperitoneal lymph node dissection inmassive chylous ascites. Eur Urol 1995; 28: 119–121.14 Geisler JP, Foster RS, Sutton GP. Chyloperitoneum follow-ing treatment for advanced gynecologic malignancies. ObstetGynecol 1994; 83: 883–885.15 Ablan CJ, Littooy FN, Freeark RJ. Postoperative chylousascites: diagnosis and treatment. Arch Surg 1990; 125:270–273.16 Gaglio PJ, Leevy CB, Koneru B. Peri-operative chylousascites. J Med 1996; 27: 369–376.17 Walker WM. Chylous ascites following pancreatoduo-denectomy. Arch Surg 1967; 95: 640–642.18 Cope C. Diagnosis and treatment of postoperative chyle leak-age via percutaneous transabdominal catheterization of thecisterna chyli: a preliminary study. J Vasc Interv Radiol 1998;9: 727–734.19 McVay CB. Thoracic cavity and its contents. In Anson BJ,McVay CB eds.: Surgical anatomy, Saunders, Philadelphia,1984; pp. 460–463.20 Petrasek AJ, Ameli FM. Conservative management of chy-lous ascites complicating aortic surgery: a case report. CanJ Surg 1996; 39: 499–501.21 Chen FP, Lo TS, Soong YK. Management of chylous ascitesfollowing laparoscopic presacral neurectomy. Hum Reprod1998; 13: 880–883.22 Hilfer CL, Holgersen LO. Massive chylous ascites and tran-sected pancreas secondary to child abuse: successful non-surgical management. Pediatr Radiol 1995; 25: 117–119.23 Staats BA, Ellefson RD, Budahn LL, Dines DE, PrakashUB, Offord K. The lipoprotein profile of chylous and nonchy-lous pleural effusion. Mayo Clin Proc 1980; 55: 700–704.24 Milsom JW. Chylothorax: an assessment of current surgicalmanagement. J Thorac Cardiovasc Surg 1985; 89: 221–227.25 Fleisher HL, Oren JW, Summers DS. Chylous ascites afterabdominal aortic aneurysmectomy: successful managementwith a peritoneovenous shunt. J Vasc Surg 1987; 6: 403–407.26 Bauwens K, Jacobi CA, Gellert K, Aurisch R, Zieren HU.Diagnosis and therapy of postoperative chyloperitoneum.Chirurg 1996; 67: 658–660.27 Pui MH, Yueh TC. Lymphoscintigraphy in chyluria, chy-loperitoneum and chylothorax. J Nucl Med 1998; 39:1292–1296.28 Cerfolio RJ, Allen MS, Deschamps C, Trastek VF, PairoleroPC. Postoperative chylothorax. J Thorac Cardiovasc Surg1996; 112: 1361–1365.

Treatment of chyloperitoneum after extended lymphatic dissection during duodenopancreatectomy

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Treatment of chyloperitoneum after extended lymphatic dissection during duodenopancreatectomy

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