BERKELEY, CA (UroToday.com) - Chylous ascites is an uncommon complication following retroperitoneal surgery, but can be quite problematic to manage.

Refractory cases not responsive to conservative measures frequently will require the placement of a peritoneovenous shunt. Here, Nishizawa and colleagues describe their experience with a case of refractory chylous ascites that occurred after a transperitoneal laparoscopic left radical nephrectomy with para-aortic lymph node dissection.

The patient was a 44 year old woman with T3bN0M1 renal cell carcinoma that developed milky ascites with oral intake on post-operative day 3. Conservative management was initially employed, including low fat diet and paracentesis, but the drainage persisted, thus the patient was put on parenteral nutrition with oral medium chain triglycerides, somatostatin analogues, and an abdominal drain was placed. The patient became weak and hypoalbuminemic due to protein losses in the ascites and therefore operative intervention was offered 6 weeks after nephrectomy. Six hours prior to surgery, the patient was given milk to drink to facilitate intraoperative identification of the lymphatic leakage point(s). The patient was explored laparoscopically and the leak could be seen from the proximal and distal ends of the lymph node dissection. These areas were suture ligated, then individual lymphatics were clipped or treated with the argon beam, and then fibrin glue was liberally sprayed over the area. At the end of the procedure, there was no evidence of continued lymphatic leak and the patient remained free of ascites 3 months postop.

Chylous ascites is a rare but troublesome complication of retroperitoneal surgery that can be refractory to conservative measures. The paradigm used in this case highlights the sequential elevation in intervention that is appropriate in the management of such patients, and further demonstrates the utility of laparoscopic approaches in operative management.

Koji Nishizawa, Noriyuki Ito, Shingo Yamamoto, Toshiyuki Kamoto & Osamu Ogawa,
International Journal of Urology - Volume 13 Page 619 - May 2006
doi:10.1111/j.1442-2042.2006.01372.x

Written by Christopher G. Wood, MD, a Contributing Editor with UroToday.

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