Chylous Ascites Management After Pancreatic Surgery

Excerpt

Chylous ascites and chyle leaks are rare complications following major surgery and arise when there have been disruptions of the major lymphatic channels such as the cisterna chyli or the thoracic duct. Chyle leaks should be suspected following pancreatic surgery when there is drainage of milky white fluid. Fluid triglyceride values are found to be elevated when measured by astute clinicians, particularly when normal fluid amylase concentrations are identified in suspicious looking drain fluid. Chyle leaks have the potential to result in adverse outcomes for patients due to loss of fluids and triglycerides resulting in malnutrition, fluid imbalances, and poor wound healing. In the setting of pancreatectomy, various treatment options have been described, but there is no consensus regarding optimal management. The manuscript published here is a review of the authors’ experience with 15 chyle leaks (2.4%) in a series of 614 patients who underwent pancreatic resections for a variety of indications at a large French University Hospital [1]. This incidence is comparable to previous reports of 2.6–3.8% [2, 3]. All patients were treated with an institutional regimen that utilized “conservative” treatment initially (TPN, medium chain triglycerides (MCT) through a feeding tube, and somatostatin analog) followed by bipedal lymphangiography (BPLAG) if the chyle leak did not resolve. Chyle leaks resolved in 10 patients treated with conservative therapy. An additional 5 patients underwent BPLAG. A site of leak was identified in two (40%) of these patients, and chyle leaks resolved in all patients following BPLAG. Statistical analysis showed that para-aortic lymph node sampling and early enteral feeding were risk factors for chyle leaks, but no significant factors predicted conservative treatment failure prompting the need for BPLAG. These findings are also consistent with previously reported data [2, 3]. The authors conclude that there is no consensus for the treatment of chyle leaks following pancreatic resection, but that conservative treatment regimens should be utilized initially and that BPLAG should be considered sooner. …