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Agrawal A, Chaddha U, Shojaee S, Nadolski G, Liberman M, Lee YCG, Rahman N, Reisenauer JS, Ferguson MK, DeCamp MM, Gillaspie EA, Bedawi EO, Currie B, Feller-Kopman DJ, Desai A, Yasufuku K, Bishay V, Gesthalter Y, Grosu H, Chick JFB, Lentz R, Kolli KP, Kaufman A, Mehta RM, Desai K, Davis H, Ghori UK, Maldonado F. Multidisciplinary management of adult patients with chylothorax: a consensus statement. Eur Respir J 2024; 64:2400470. [PMID: 39326915 DOI: 10.1183/13993003.00470-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 09/04/2024] [Indexed: 09/28/2024]
Abstract
The management of chylothorax remains challenging given the limited evidence and significant heterogeneity in practice. In addition, there are no practical guidelines on the optimal approach to manage this complex condition. We convened an international group of 27 experts from 20 institutions across five countries and four specialties (pulmonary, interventional radiology, thoracic surgery and nutrition) with experience and expertise in managing adult patients with chylothorax. We performed a literature and internet search for reports addressing seven clinically relevant PICO (Patient, Intervention, Comparison and Outcome) questions pertaining to the management of adult patients with chylothorax. This consensus statement, consisting of best practice statements based on expert consensus addressing these seven PICO questions, was formulated by a systematic and rigorous process involving the evaluation of published evidence, augmented with provider experience. Panel members participated in the development of the final best practice statements using the modified Delphi technique. Our consensus statement aims to offer guidance in clinical decision making when managing patients with chylothorax while also identifying gaps in knowledge and informing future research.
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Affiliation(s)
- Abhinav Agrawal
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
- Contributed equally as joint first authors
| | - Udit Chaddha
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Contributed equally as joint first authors
| | - Samira Shojaee
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | - Y C Gary Lee
- University of Western Australia, Perth, Australia
| | - Najib Rahman
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | | | | | - Malcolm M DeCamp
- Division of Cardiothoracic Surgery, University of Wisconsin, Madison, WI, USA
| | | | - Eihab O Bedawi
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Brian Currie
- New York-Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
| | - David J Feller-Kopman
- Pulmonary and Critical Care Medicine, Darmouth-Hitchcock Medical Center, The Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Ajinkya Desai
- University of Mississippi Medical Center, Jackson, MS, USA
| | - Kazuhiro Yasufuku
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Vivian Bishay
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yaron Gesthalter
- Division of Pulmonary, Critical Care, Allergy and Sleep, University of California San Francisco, San Francisco, CA, USA
| | - Horiana Grosu
- University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | | | - Robert Lentz
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - K Pallav Kolli
- Division of Body Interventional Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Andrew Kaufman
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ravindra M Mehta
- Apollo Bangalore Pulmonary Services, Apollo Hospitals Bangalore, Bangalore, India
| | - Kush Desai
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Heather Davis
- University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | | | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Umar A, Faquih AE, Bilal M, Garner J. Navigating the Labyrinth: Chylothorax and Chylous Ascites Unveiled After Abdominal Surgery for an Exceptionally Rare Tumor. Cureus 2024; 16:e66239. [PMID: 39238722 PMCID: PMC11375108 DOI: 10.7759/cureus.66239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2024] [Indexed: 09/07/2024] Open
Abstract
Schwannomas, originating from the Schwann sheath of peripheral or cranial nerves, are rare tumors commonly found in the head and neck or extremities. Adrenal schwannomas, however, are exceedingly rare, accounting for less than 1% of all adrenal tumors. Here, we present a case of a 31-year-old Caucasian woman diagnosed with an adrenal schwannoma, which was incidentally discovered during imaging studies for an unrelated issue. Following laparoscopic adrenalectomy, the patient developed chylous ascites (CA) and coexistent chylothorax, posing a diagnostic challenge and necessitating a multidisciplinary approach to management.
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Affiliation(s)
- Anam Umar
- Internal Medicine, Ascension St. Vincent's Birmingham, Birmingham, USA
| | - Amber E Faquih
- Infectious Diseases, University of Alabama at Birmingham, Birmingham, USA
| | - Muhammad Bilal
- Internal Medicine, Ascension St. Vincent's Birmingham, Birmingham, USA
| | - Jeffery Garner
- Pulmonary and Critical Care, Ascension St. Vincent's Birmingham, Birmingham, USA
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Syrnioti G, Al Awwa G, Eisdorfer J. Chyloperitoneum After Penetrating Abdominal Trauma: A Report of a Rare Case. Cureus 2023; 15:e40188. [PMID: 37431330 PMCID: PMC10329858 DOI: 10.7759/cureus.40188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2023] [Indexed: 07/12/2023] Open
Abstract
The term chyloperitoneum refers to the accumulation of triglyceride-rich fluid in the peritoneal cavity. It is an uncommon clinical condition that usually occurs due to disruption of lymphatic flow secondary to trauma or obstruction. Common causes include penetrating or blunt trauma, iatrogenic injuries, congenital anomalies, malignant neoplasms, infections such as tuberculosis and filariasis, liver cirrhosis, constrictive pericarditis, congestive heart failure, inflammatory conditions, such as sarcoidosis and pancreatitis, and radiation- and drug-related pathologies. We present a case of chyloperitoneum in a 33-year-old woman secondary to penetrating abdominal trauma secondary to a gunshot wound. The patient was successfully managed with total parenteral nutrition and octreotide administration. To our knowledge, this is the only case of chylous ascites caused by a penetrating injury that has been reported in the literature. Conservative management with the initiation of total parenteral nutrition and octreotide led to the resolution of this condition.
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Affiliation(s)
- Georgia Syrnioti
- Surgery, Brookdale University Hospital Medical Center, New York, USA
| | - Ghayth Al Awwa
- Surgery, Brookdale University Hospital Medical Center, New York, USA
| | - Jacob Eisdorfer
- Surgery, Brookdale University Hospital Medical Center, New York, USA
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Barrera L, Gonzalez D, Pelaez L. Chylous Ascites Related to Radiotherapy in a Patient With Gastric Cancer. Cureus 2023; 15:e38716. [PMID: 37292563 PMCID: PMC10246730 DOI: 10.7759/cureus.38716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2023] [Indexed: 06/10/2023] Open
Abstract
Chylous ascites is an uncommon complication seen in patients who have received radiotherapy to the abdomen. However, the morbidity caused by peritoneal ascites makes this an important complication to be considered when giving abdominal radiation to oncology patients. We present the case of a 58-year-old woman with gastric adenocarcinoma, who consulted for recurrent ascites after receiving abdominal radiotherapy as an adjuvant treatment to surgery. Different tests were carried out to evaluate the cause. Malignant abdominal relapse and infection were ruled out. Paracentesis evidenced swallowed fluid, therefore, the possibility of chylous ascites due to radiotherapy was considered. Intrathoracic, abdominal, and pelvic lymphangiography was performed with Lipiodol and the absence of cisterna chyli was confirmed as the cause of refractory ascites. After the diagnosis, the patient went under aggressive in-hospital nutritional support treatment, with clinico-radiological response.
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Affiliation(s)
- Leidy Barrera
- General Medicine, Universidad Pontificia Bolivariana, Medellin, COL
| | - Diego Gonzalez
- Oncology, Instituto de Cancerologia Las Américas, Medellin, COL
| | - Luisa Pelaez
- Oncology Nursing, Instituto de Cancerologia Las Américas, Medellin, COL
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Duletzke NT, Kiraly LN, Martindale RG. Chylothorax and chylous ascites: Overview, management, and nutrition. Nutr Clin Pract 2023; 38:557-563. [PMID: 36938719 DOI: 10.1002/ncp.10973] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 03/21/2023] Open
Abstract
Chyle leaks of any source or type can cause significant morbidity and mortality. Attention to the anatomy and physiology of the leak, followed by stepwise dietary and pharmacologic management, obviates the need for surgical intervention in a majority of patients. In this article, we review the importance, etiology, anatomy, diagnosis, nutrition and immunologic effects, and options for treatment of chylothorax and chylous ascites based on experience and prior literature. We propose a multidisciplinary approach to optimize these treatments including the primary surgical teams, pharmacists, and dietitians, with reoperation as a last resort to minimize the morbidity of this challenging complication.
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Affiliation(s)
- Nicholas T Duletzke
- Department of Surgery, Oregon Health and Science University, Oregon, Portland, USA
| | - Laszlo N Kiraly
- Department of Surgery, Oregon Health and Science University, Oregon, Portland, USA
| | - Robert G Martindale
- Department of Surgery, Oregon Health and Science University, Oregon, Portland, USA
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Sakai L, Aguilera P, Karmegam S. Acute Chylous Ascites Status Post Median Arcuate Ligament Syndrome Decompression: A Unique Case Report and Literature Review. Cureus 2023; 15:e35300. [PMID: 36968858 PMCID: PMC10037925 DOI: 10.7759/cureus.35300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 02/21/2023] [Indexed: 02/24/2023] Open
Abstract
Chylous ascites (CA) are a rare finding of triglyceride-rich peritoneal fluid within the abdominal cavity. Malignancy, cirrhosis, and trauma after abdominal surgery are the leading causes of CA in adults. Currently, there are no published guidelines on the management of CA. This report describes a case of an 18-year-old female presenting with abdominal pain and distention following median arcuate ligament syndrome (MALS) decompression. A computed tomography (CT) of the abdomen and pelvis showed large-volume ascites with normal hepatic morphology. Paracentesis and ascitic fluid studies were positive for milky fluid rich in triglyceride. Her recent history of MALS decompression revealed the cause of her acute CA to be a postoperative complication from her abdominal surgery. This case highlights the diverse etiology of ascites and the importance of a careful history and physical examination when evaluating adults with ascites.
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Gil González Y, Laseca-Modrego M, Arencibia-Sánchez O, González García-Cano D, Martin Martinez AI. Chylous Ascites Secondary to Retroperitoneal Para-Aortic Lymphadenectomy: A Case Report. Cureus 2022; 14:e22560. [PMID: 35345705 PMCID: PMC8957285 DOI: 10.7759/cureus.22560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2022] [Indexed: 11/25/2022] Open
Abstract
Chylous ascites is caused by an accumulation of lymphatic fluid in the peritoneal cavity secondary to a rupture or obstruction of the abdominal lymphatic ducts. It has a milky appearance and is rich in triglycerides. The most frequent etiologies are neoplasms, liver cirrhosis, and ruptured lymphatic vessels after abdominal surgery. Clinically, it manifests as abdominal distention and increased abdominal girth. The presence of triglycerides in ascites fluid is the most useful diagnostic criterion. Treatment consists of a high-protein diet with fat restriction and medium-chain triglyceride supplements. Surgery is reserved for refractory cases. We present the case of a 66-year-old patient with a diagnosis of chylous ascites secondary to retroperitoneal lymphadenectomy.
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Gorroño Zamalloa I, Markuleta Iñurritegi M, Urtasun Arlegui L, Orive Calzada A. Chylous ascites secondary to diffuse large B cell lynphoma. A case report. GASTROENTEROLOGIA Y HEPATOLOGIA 2021; 45:488-489. [PMID: 34273424 DOI: 10.1016/j.gastrohep.2021.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 06/16/2021] [Accepted: 06/28/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Irati Gorroño Zamalloa
- Servicio de Aparato Digestivo, Hospital Universitario de Araba, Vitoria-Gasteiz, Araba, España.
| | | | - Leire Urtasun Arlegui
- Servicio de Aparato Digestivo, Hospital Universitario de Araba, Vitoria-Gasteiz, Araba, España
| | - Aitor Orive Calzada
- Servicio de Aparato Digestivo, Hospital Universitario de Araba, Vitoria-Gasteiz, Araba, España
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Rajesh S, George T, Philips CA, Ahamed R, Kumbar S, Mohan N, Mohanan M, Augustine P. Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update. World J Gastroenterol 2020; 26:5561-5596. [PMID: 33088154 PMCID: PMC7545393 DOI: 10.3748/wjg.v26.i37.5561] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/31/2020] [Accepted: 08/29/2020] [Indexed: 02/06/2023] Open
Abstract
More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic portosystemic shunt (TIPS) procedure continues to remain a focus of intense clinical and biomedical research. By the impressive reduction in portal pressure achieved by this intervention, coupled with its minimally invasive nature, TIPS has gained increasing acceptance in the treatment of complications of portal hypertension. The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy. Moreover, the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions, which was occasionally severe. While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents, hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS. It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS. The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax, portal hypertensive gastropathy, ectopic varices, hepatorenal and hepatopulmonary syndromes, non-tumoral portal vein thrombosis and chylous ascites. It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality. The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.
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Affiliation(s)
- Sasidharan Rajesh
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Tom George
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Rizwan Ahamed
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Sandeep Kumbar
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Narain Mohan
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Meera Mohanan
- Anesthesia and Critical Care, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
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Cocomazzi F, Castellaneta NM, Castellaneta A, Fucilli F, Ierardi E, Di Leo A. Transjugular intrahepatic portosystemic shunt for a patient with chylothorax in cryptogenic/metabolic cirrhosis. Hepatobiliary Pancreat Dis Int 2020; 19:303-304. [PMID: 32284259 DOI: 10.1016/j.hbpd.2020.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 03/10/2020] [Indexed: 02/05/2023]
Affiliation(s)
- Francesco Cocomazzi
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | | | - Antonino Castellaneta
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Fabio Fucilli
- Radiology Unit, IRCCS De Bellis, Castellana Grotte, Bari, Italy
| | - Enzo Ierardi
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Alfredo Di Leo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy.
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Bhardwaj R, Vaziri H, Gautam A, Ballesteros E, Karimeddini D, Wu GY. Chylous Ascites: A Review of Pathogenesis, Diagnosis and Treatment. J Clin Transl Hepatol 2018; 6:105-113. [PMID: 29577037 PMCID: PMC5863006 DOI: 10.14218/jcth.2017.00035] [Citation(s) in RCA: 145] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Revised: 09/26/2017] [Accepted: 09/30/2017] [Indexed: 12/12/2022] Open
Abstract
Chylous ascites (CA) is a rare form of ascites that results from the leakage of lipid-rich lymph into the peritoneal cavity. This usually occurs due to trauma and rupture of the lymphatics or increased peritoneal lymphatic pressure secondary to obstruction. The underlying etiologies for CA have been classified as traumatic, congenital, infectious, neoplastic, postoperative, cirrhotic or cardiogenic. Since malignancy and cirrhosis account for about two-thirds of all the cases of CA in Western countries, in this article we have attempted to reclassify CA based on portal and non-portal etiologies. The diagnosis of CA is based on the distinct characteristic of the ascitic fluid which includes a milky appearance and a triglyceride level of >200 mg/dL. The management consists of identifying and treating the underlying disease process, dietary modification, and diuretics. Some studies have also supported the use of agents such as orlistat, somatostatin, octreotide and etilefrine. Paracentesis and surgical interventions in the form of transjugular intrahepatic portosystemic shunt (commonly known as TIPS), peritoneal shunt, angiography with embolization of a leaking vessel, and laparotomy remain as treatment options for cases refractory to medical management.
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Affiliation(s)
- Richa Bhardwaj
- Department of Medicine, Division of Gastroenterology-Hepatology, UCONN Health, Farmington, CT, USA
- *Correspondence to: Richa Bhardwaj, Department of Medicine, Division of Gastroenterology-Hepatology, UCONN Health, Farmington, CT 06030, USA. Tel/Fax: +1-860-679-4613, E-mail:
| | - Haleh Vaziri
- Department of Medicine, Division of Gastroenterology-Hepatology, UCONN Health, Farmington, CT, USA
| | - Arun Gautam
- Department of Medicine, Division of Gastroenterology-Hepatology, UCONN Health, Farmington, CT, USA
| | | | - David Karimeddini
- Department of Diagnostic Imaging and Therapeutics, UCONN Health, Farmington, CT, USA
| | - George Y. Wu
- Department of Medicine, Division of Gastroenterology-Hepatology, UCONN Health, Farmington, CT, USA
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Lizaola B, Bonder A, Trivedi HD, Tapper EB, Cardenas A. Review article: the diagnostic approach and current management of chylous ascites. Aliment Pharmacol Ther 2017; 46:816-824. [PMID: 28892178 DOI: 10.1111/apt.14284] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 07/15/2017] [Accepted: 08/11/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND Chylous ascites is rare, accounting for less than 1% of cases. An appropriate and stepwise approach to its diagnosis and management is of key importance. AIM To review the current diagnostic approach and management of chylous ascites. METHODS A literature search was conducted using PubMed using the key words 'chylous', 'ascites', 'cirrhosis', 'pathophysiology', 'nutritional therapy', 'paracentesis", "transjugular intrahepatic portosystemic shunt" and "TIPSS'. Only articles in English were included. RESULTS Chylous ascites is caused by the traumatic or obstructive disruption of the lymphatic system that leads to extravasation of thoracic or intestinal lymph into the abdominal space and the accumulation of a milky fluid rich in triglycerides. The most common causes are malignancy, cirrhosis and trauma after abdominal surgery. This condition can lead to chyle depletion, which results in nutritional, immunologic and metabolic deficiencies. An ascitic triglyceride concentration above 200 mg/dL is consistent with chylous ascites. Treatment is based on management of the underlying cause and nutritional support. CONCLUSIONS Chylous ascites is mostly due to malignancy and cirrhosis in adults, and congenital lymphatic disorders in children. Treatment with nutritional optimization and management of the underlying etiology are the cornerstones of therapy. When conservative measures fail, other interventions such as octreotide/somatostatin analogues, surgical ligation, embolization and transjugular intrahepatic portosystemic shunt in patients with cirrhosis can be considered.
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Affiliation(s)
- B Lizaola
- Department of Medicine, St. Elizabeth Medical Center, Brighton, MA, USA
| | - A Bonder
- Liver Center, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - H D Trivedi
- Liver Center, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - E B Tapper
- Department of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - A Cardenas
- GI/Liver Unit, Institute of Digestive Diseases and Metabolism, University of Barcelona, Hospital Clinic and Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Barcelona, Spain
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Ng ZQ, He B. A Proposed Classification System and Therapeutic Strategy for Chyle Leak After Laparoscopic Living-Donor Nephrectomy: A Single-Center Experience and Review of the Literature. EXP CLIN TRANSPLANT 2017; 16:143-149. [PMID: 29108520 DOI: 10.6002/ect.2016.0305] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Zi Qin Ng
- From the WA Liver and Kidney Transplant Service, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
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15
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Tsauo J, Shin JH, Han K, Yoon HK, Ko GY, Ko HK, Gwon DI. Transjugular Intrahepatic Portosystemic Shunt for the Treatment of Chylothorax and Chylous Ascites in Cirrhosis: A Case Report and Systematic Review of the Literature. J Vasc Interv Radiol 2016; 27:112-6. [PMID: 26723922 DOI: 10.1016/j.jvir.2015.09.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 09/25/2015] [Accepted: 09/26/2015] [Indexed: 02/07/2023] Open
Abstract
Cirrhosis-related chylothorax and chylous ascites are rare conditions. The pathophysiologic mechanism of cirrhosis-related chylous fluid collections is believed to be excessive lymph flow resulting from portal hypertension. Transjugular intrahepatic portosystemic shunt (TIPS) creation is a well-established method for reducing portal hypertension. The case of a 61-year-old man with cirrhosis-related chylothorax treated successfully with a TIPS is described. A systematic review of the literature revealed nine additional cases of chylothorax or chylous ascites treated successfully with a TIPS. These cases showed that TIPS creation may be effective and safe for the treatment of chylous fluid collections in patients with cirrhosis.
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Affiliation(s)
- Jiaywei Tsauo
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, 86, Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, 86, Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea.
| | - Kichang Han
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, 86, Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
| | - Hyun-Ki Yoon
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, 86, Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
| | - Gi-Young Ko
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, 86, Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
| | - Heung-Kyu Ko
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, 86, Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
| | - Dong-Il Gwon
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, 86, Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
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16
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Ilhan E, Demir U, Alemdar A, Ureyen O, Eryavuz Y, Mihmanli M. Management of high-output chylous ascites after D2-lymphadenectomy in patients with gastric cancer: a multi-center study. J Gastrointest Oncol 2016; 7:420-425. [PMID: 27284475 PMCID: PMC4880771 DOI: 10.21037/jgo.2016.02.03] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 01/06/2016] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND This study aimed to propose treatment strategies for high-output chylous ascites (CA) developed after gastric cancer surgery. METHODS The data of patients with CA after gastric cancer surgery in three high volume Training and Research Hospitals between 2005 and 2015 were retrospectively evaluated. RESULTS Nine patients out of 436 gastrectomies were detected with CA. The mean amount of daily fistula output was 939 mL. Treatment consisted of cessation of oral feeding, total parenteral nutrition (TPN), somatostatin analogs administration, clamping and/or removal of the drainage tube, diuretic administration and diet therapy with medium-chain triglycerides (MCTs) alone or in combination. The mean fistula closure time and length of hospital stay were 23 and 24 days respectively. Hemopneumothorax developed during right subclavian vein catheterisation for TPN implementation in one patient. There was no mortality. CONCLUSIONS Combined cessation of oral feeding and TPN are usually used for treatment of CA as first-line treatment. However, TPN is no harmless. Although our data are limited they do allow us to conclude that diet with MCT's may use for medical treatment of CA as first-line.
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17
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A Large Pleural Effusion following Abdominal Aortic Surgery. Case Rep Pulmonol 2015; 2015:254010. [PMID: 26635989 PMCID: PMC4655280 DOI: 10.1155/2015/254010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 09/27/2015] [Indexed: 02/07/2023] Open
Abstract
Chylous ascites and coexistent chylothorax is a rare but important complication following retroperitoneal abdominal surgery. We report a 70-year-old male who developed gradual abdominal distension, chest tightness, and dyspnea five months after having an uncomplicated aortobifemoral bypass performed. Physical examination was consistent with a large right sided effusion and ascites which were confirmed by computed tomography. Thoracentesis yielded an opaque milky fluid with analysis consistent with a chylothorax with a paracentesis revealing fluid that was similar in both appearance and biochemistry. The patient failed initial conservative management so a chest tube was placed followed by chemical pleurodesis. We review the literature of the pathophysiology and treatment approach to such a pleural effusion.
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18
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Piña-Pedraza J, Álvarez-Avalos L, Vargas-Espinosa J, Salcedo-Gómez A, Carranza-Madrigal J. Chylous ascites secondary to cirrhosis of the liver: A case report. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2015. [DOI: 10.1016/j.rgmxen.2015.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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19
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Piña-Pedraza JP, Álvarez-Avalos L, Vargas-Espinosa JM, Salcedo-Gómez A, Carranza-Madrigal J. Chylous ascites secondary to cirrhosis of the liver: A case report. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2015; 80:285-7. [PMID: 26298450 DOI: 10.1016/j.rgmx.2015.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 04/08/2015] [Accepted: 04/24/2015] [Indexed: 02/07/2023]
Affiliation(s)
- J P Piña-Pedraza
- Servicio de Medicina Interna, Hospital General «Dr. Miguel Silva» Secretaria de Salud, Morelia Michoacán, México
| | - L Álvarez-Avalos
- Servicio de Medicina Interna, Hospital General «Dr. Miguel Silva» Secretaria de Salud, Morelia Michoacán, México; Universidad Michoacana de San Nicolás de Hidalgo, Morelia Michoacán, México.
| | - J M Vargas-Espinosa
- Servicio de Medicina Interna, Hospital General «Dr. Miguel Silva» Secretaria de Salud, Morelia Michoacán, México
| | - A Salcedo-Gómez
- Servicio de Medicina Interna, Hospital General «Dr. Miguel Silva» Secretaria de Salud, Morelia Michoacán, México
| | - J Carranza-Madrigal
- Servicio de Medicina Interna, Hospital General «Dr. Miguel Silva» Secretaria de Salud, Morelia Michoacán, México
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20
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Chylous Ascites: Evaluation and Management. ISRN HEPATOLOGY 2014; 2014:240473. [PMID: 27335837 PMCID: PMC4890871 DOI: 10.1155/2014/240473] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Accepted: 12/19/2013] [Indexed: 02/07/2023]
Abstract
Chylous ascites refers to the accumulation of lipid-rich lymph in the peritoneal cavity due to disruption of the lymphatic system secondary to traumatic injury or obstruction. Worldwide, abdominal malignancy, cirrhosis, and tuberculosis are the commonest causes of CA in adults, the latter being most prevalent in developing countries, whereas congenital abnormalities of the lymphatic system and trauma are commonest in children. The presence of a milky, creamy appearing ascitic fluid with triglyceride content above 200 mg/dL is diagnostic, and, in the majority of cases, unless there is a strong suspicion of malignancy, further investigations are not required in patients with cirrhosis. If an underlying cause is identified, targeted therapy is possible, but most cases will be treated conservatively, with dietary support including high-protein and low-fat diets supplemented with medium-chain triglycerides, therapeutic paracentesis, total parenteral nutrition, and somatostatins. Rarely, resistant cases have been treated by transjugular intrahepatic portosystemic shunt, surgical exploration, or peritoneovenous shunt.
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21
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Talluri SK, Nuthakki H, Tadakamalla A, Talluri J, Besur S. Chylous ascites. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2012; 3:438-40. [PMID: 22362456 PMCID: PMC3271402 DOI: 10.4297/najms.2011.3438] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Context: Chylous ascites is the accumulation of milky chyle in the peritoneal cavity. Chylous ascites has been reported after surgeries like abdominal aortic aneurysm repair, radical gastrectomy, duodenectomy, nephrectomy and Wilm's tumor resection. Our literature search did not reveal any reports of chylous ascites after a gastric ulcer resection. We report about an elderly woman with a rare complication of chylous ascites after an emergent surgery for a perforated gastric ulcer. Case Report: A 70-year-old woman developed sudden respiratory distress on 5th post-operative day after an elective C3-C7 cervical discectomy and fusion. Her past medical history was significant for cervical spondylosis. The Computed Tomography (CT) scan of the chest revealed air under the diaphragm suspicious for hollow viscus perforation. She underwent an emergent surgery for drainage of hematoma in the neck along with an emergent laparotomy to repair a large perforated gastric ulcer distal to the gastro-esophageal junction. The patient had worsening of abdominal distention on 4th post-operative day. The CT scan of abdomen showed fluid collection in the abdomen. The abdominal drain revealed large amount of serous milky fluid at the rate of 1500 ml per day. The fluid analysis showed that the triglyceride level was 170 mg/dl and cholesterol level was 15 mg/dl. The fluid cultures did not grow any organism. She responded to treatment with octreotide and a diet of medium chain triglyceride oil. Conclusion: Any obstruction or damage to the lymphatic channels results in chylous ascites. Lymphomas, metastatic malignancies, and abdominal surgeries commonly cause chylous ascites. Ascitic fluid triglyceride level greater than 110 mg/dl is diagnostic of chylous ascites. Chylous ascites is a rare complication of a peptic ulcer resection which can be managed effectively with octreotide.
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Affiliation(s)
- Siva K Talluri
- Department of Internal Medicine, Michigan State University Internal Medicine Residency Program, McLaren Regional Medical Center, Flint, Michigan, USA
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22
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Barakat HM, Shahin Y, McCollum P. Chylous ascites complicating elective abdominal aortic aneurysm repair: case report and review of treatment options. Vasc Endovascular Surg 2012; 46:682-5. [PMID: 22903333 DOI: 10.1177/1538574412457083] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Chylous ascitis is a rare complication of abdominal aortic aneurysm (AAA) surgery with only 38 cases reported since the early 70s. Due to their anatomical relation with the abdominal aorta, cisterna chyli injury is more common following open AAA repairs when compared to other surgeries; 81% of all postsurgical chylous ascites reported. CASE PRESENTATION We present a case of severe chylous ascitis following elective AAA repair in a 76-year-old caucasian male who gradually developed abdominal distension following discharge. A conservative approach was followed by a peritoneovenous shunt insertion, but this had no clinical benefit. The site of chyle leak was identified and ligated at relaparatomy to eventually resolve his ascitis. CONCLUSION Many reports in literature demonstrate successful conservative measures and highlight the importance of nutritional status in the course of persistent postoperative chylous ascitis. In our experience, complete resolution only came after relaparatomy and repair of leaking lymphatics.
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Affiliation(s)
- Hashem M Barakat
- Academic Vascular Surgical Unit, Hull York Medical School, University of Hull, Hull, United Kingdom.
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23
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Abstract
Chylous ascites is rare in clinical practice. It is characterized by milky-appearing peritoneal fluid with a triglycerides concentration of >1.25 mmol/l (110 mg/dl). Its pathophysiology is related to a disruption in the normal lymphatic flow. It is more common after trauma (including post surgery), neoplasia or atypical infections such as tuberculosis or filariasis. Other rare medical causes have been reported. The treatment is supportive and focused on correction of the underlying pathology. We report here the first case of chylous ascites caused by giant liver hemangioma and discuss the management of this condition.
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Affiliation(s)
- Darius L Lazarus
- Department of Medicine, McGill University, Montreal, Que., Canada
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24
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Senosiain Lalastra C, Martínez González J, Mesonero Gismero F, Moreira Vicente V. [Octreotide treatment for postoperative chylous ascites in an adult]. GASTROENTEROLOGIA Y HEPATOLOGIA 2012; 35:567-71. [PMID: 22608492 DOI: 10.1016/j.gastrohep.2012.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2012] [Revised: 03/14/2012] [Accepted: 03/21/2012] [Indexed: 02/07/2023]
Abstract
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.
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25
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Kang CM, Kim S, Kim BW, Kim KS, Choi JS, Lee WJ, Kim BR. Acute chylous peritonitis mimicking ovarian torsion in a patient with advanced gastric carcinoma. J Korean Med Sci 2007; 22 Suppl:S164-6. [PMID: 17923746 PMCID: PMC2694377 DOI: 10.3346/jkms.2007.22.s.s164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The extravasation of chyle into the peritoneal space usually does not accompany an abrupt onset of abdominal pain with symptoms and signs of peritonitis. The rarity of this condition fails to reach preoperative diagnosis prior to laparotomy. Here, we introduce a case of chylous ascites that presented with acute abdominal pain mimicking peritonitis caused by ovarian torsion in a 41-yr-old female patient with advanced gastric carcinoma. An emergency exploratory laparotomy was performed but revealed no evidence of ovarian torsion. Only chylous ascites was discovered in the operative field. She underwent a complete abdominal hysterectomy and salphingo-oophorectomy. Only saline irrigation and suction-up were performed for the chylous ascites. The postoperative course was uneventful. Her bowel movement was restored within 1 week. She was allowed only a fat-free diet, and no evidence of re-occurrence of ascites was noted on clinical observation. She now remains under consideration for additional chemotherapy.
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Affiliation(s)
- Chang Moo Kang
- Department of Surgery and Women's Cancer Clinic, Yonsei University College of Medicine, Seoul, Korea
| | - Sunghoon Kim
- Department of Obstetrics and Gynecology, Yonsei University College of Medicine, Seoul, Korea
| | - Bub Woo Kim
- Department of Surgery and Women's Cancer Clinic, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Sik Kim
- Department of Surgery and Women's Cancer Clinic, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Sub Choi
- Department of Surgery and Women's Cancer Clinic, Yonsei University College of Medicine, Seoul, Korea
| | - Woo Jung Lee
- Department of Surgery and Women's Cancer Clinic, Yonsei University College of Medicine, Seoul, Korea
| | - Byong Ro Kim
- Department of Surgery and Women's Cancer Clinic, Yonsei University College of Medicine, Seoul, Korea
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26
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Abstract
RNA interference (RNAi) is a potent method of gene silencing that has developed rapidly over the past few years as a result of its extensive importance in the study of genetics, molecular biology and physiology. RNAi technology has also recently yielded significant insight into the innate and adaptive immune systems by helping to elucidate numerous mechanisms that regulate the development, activation and function of cells that mediate immunity. In addition, because of its ability to suppress gene expression effectively, this technique may be used to regulate the immune response for clinical purposes. Nonetheless, before RNAi can be successfully administered into human patients as a medical treatment, it is necessary to overcome several major limitations of this technology, such as inefficient in vivo delivery, incomplete silencing of target genes, non-specific immune responses, and off-target effects. As novel developments and discoveries in molecular biology swiftly continue to unfold, it is likely that RNAi may soon translate into a potent form of in vivo gene silencing with profound applications to vaccination and immunotherapy. In the present review, we examine the current progress of immunological studies employing RNAi and discuss the prospects for the implementation of this technique in the clinical arena.
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Affiliation(s)
- Chih-Ping Mao
- Department of Pathology, The Johns Hopkins University School of MedicineBaltimore, MD, USA
| | - Yen-Yu Lin
- Department of Pathology, The Johns Hopkins University School of MedicineBaltimore, MD, USA
| | - Chien-Fu Hung
- Department of Pathology, The Johns Hopkins University School of MedicineBaltimore, MD, USA
- Department of Oncology, The Johns Hopkins University School of MedicineBaltimore, MD, USA
| | - T-C Wu
- Department of Pathology, The Johns Hopkins University School of MedicineBaltimore, MD, USA
- Department of Oncology, The Johns Hopkins University School of MedicineBaltimore, MD, USA
- Department of Obstetrics and Gynecology, The Johns Hopkins University School of MedicineBaltimore, MD, USA
- Department of Molecular Microbiology and Immunology, The Johns Hopkins University School of MedicineBaltimore, MD, USA
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