Book Review

Conservative Management of Chylous Ascites after Elective Abdominal Aortic Aneurysm Surgery

Sven Ross Mathisen MD, Ph.D1*, Thomas Larzon, MD2

1Dept of Vasc Surg, SIHF-Hamar, Norway
2Dept of Cardio-Vascular and Thoracic Surgery, Örebro Univ Hospital, Orebro, Sweden

*Corresponding author: Dr. Sven Ross Mathisen, M.D., Ph.D, Dept. of Vascular Surgery, SIHF – Hamar, Skolegt. 32, 2326
Hamar, Norway, Tel: +47 91638282, Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

 Submitted: 06-15-2017 Accepted: 07-21-2017 Published: 07-21-2017

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Abstract

Chylous ascites occurs rarely after elective open surgery for abdominal aortic aneurysms (AAA). The aim of this case report is to present a rare case of Chylous Ascites that was successfully treated conservatively. Reported cases are rare in the literature. An exception is an investigation team that found 22 published cases in a literature review in 1993 in addition to their own five cases. Small lymphatic vessels are severed while dissecting into and around the proximal abdominal aortic aneurysm neck. The clinical presentation is extreme and varies from transitional abdominal distention to fulminant sepsis and death. Early laparoscopic reoperation with ligation of lymphatic vessels is recommended in the literature. Conservative treatment on a rare occasion, as in our case report, may be considered if the patient is clinically stable and not septic.


Keywords: Abdominal Aortic Aneurysm, Open Surgery, Chylous Ascites, Straight Tube Vascular Prosthesis, Complications To Aortic Surgery, Conservative Treatment

 

Case Report

A 67-year-old male who was previously surgically treated for a spinal disc herniation also had hypertension that was medically treated. Due to a DVT he was put on Coumadin. In March, 2008 his 61 mm in anterior-posterior (AP) diameter infrarenal abdominal aortic aneurysm (AAA) was treated electively with a straight tube16 mm coated Dacron knitted prosthesis (Uni-graftRK DV, B.Braun, Braun Medicals Limited, UK). During the surgery the retroperitoneal layer was dissected using diathermy and surgical scissors. No major lymphatic vessels were seen near the ligament of Treitz and further up towards the left kidney vein. The inferior mesenteric vein was transected and ligated. After three days of parenteral crystalloid fluid intravenous infusion and restricted amounts of water orally, the patient began eating a normal diet. Ten days postoperatively a milky viscous grey-white fluid started effusing from the ventral laparotomy incision without signs of wound rupture or sepsis. The patient’s abdomen was without clinical signs of guarding or peritonitis. CT Abdomen with contrast showed peritoneal fluid at the level of the liver and pelvis. (Figure 1 & 2)


Under ultrasound guidance a laparocentesis was performed with a pigtail catheter placed in the lower left abdominal quadrant. 4 600 milliliters of chylous ascites was immediately removed. 8 000 milliliters was drained. This fluid was sent to culturing and resistance determination. The microbiology lab cultured and identified Staphylococcus Albus. These pathogens were sensitive to Ciproflocsacinlactat and Clindamycin, which were administered orally. CRP fell from an initial 174 to 10 mg/L. The laparotomy incision healed after two weeks on oral antibiotic treatment. The patient’s temperature, hemoglobin, and S-albumin values normalized.

Case fig 4.1

Figure 1. CT Angiogram showing chylous ascites fluid collection circumferentially inside the abdominal wall at the level of the liver. See red arrows.

 

Case fig 4.2

Figure 2. Chylous ascites fluid collection in the pelvis. See red arrows.

 

As a complication to the surgical trauma of open abdominal aortic surgery and not the developing chylous ascites the patient developed congestive heart failure (CHF) with dyspnoea and oedema. ProBNP value was slightly elevated (207 pmol/L). Oxygen – saturation fell to 85%. Myocardial enzyme Troponin T values were similar to those seen in Non-STEMI (Non-ST Elevation Myocardial Infarction). Four years post operatively the patient remains healthy without any symptoms or signs that could suggest vascular prosthesis infection.

 

Discussion

Preparing the infra-renal abdominal aortic aneurysm neck for aortic cross clamping may require extensive dissection. Under dissection lymphatic vessels may become severed anteriorly. Posteriorly the cisterna chyli and ductus lymphaticus may become damaged and lead to a retroperitoneal lymphocoele [1]. The diagnosis is made with a laparocentesis [2]. Laparoscopy is also recommended for both diagnosis and treatment [3,4].


Extensive use of diathermy, ligation, Ultracision Harmonic Scalpel (Harmonic AceR, Ethicon Endo-Surgery, LLC Guaynabo, Puerto Rico, 00969 U.S.A.) clips or LigaSure Tissue Fusion Device (LigaSureTM, CovedianTM, U.S.A.) may reduce the problem. It has been reported that postoperative fasting reduces the chylous volume and the torn vessels may heal and seal [5]. Lymphatic vessels with a lateral tear are less likely to heal than those that are transected [6]. Most para-aortic lymphatic vessels heal rapidly and spontaneously [7-9].


Pabst el al [10] reported 27 cases: occurred during AAA surgery, during aorto-bifemoral surgery for PAD and during resection of infected abdominal aortic vascular prostheses. Treatment options in the 27 reported cases with response rates were: 1) Paracentesis + total parenteral nutrition (TPN) and medium chain triglycerides (MCT) 57 %. 2) TPN +/- Paracentesis / diuretics 60 %. 3) Peritoneo-venous shunt 80 %. 4) Laparotomy with lymphatic vessel ligation 100 %. Laparoscopic ligation might be used in the future [4,5].


Conservative treatment alone was sufficient to seal and heal the severed lymphatic vessels without the use of parenteral nutrition.

 

Conclusion

Conservative treatment alone with oral antibiotics and laparocentesis drainage resulted in wound healing; cessation of lymphatic vessel leakage and graft infection could not be detected at four years. This case is rather the exception than the rule when treating such patients. None the less it´s documentation is also of value.

 

Ethics Committee
The guidelines of the ethics committee has been followed and we have obtained permission from the patient to print this case report.

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References

 

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3. Campisi C, Bellini C, Eretta C, Zill A, da Rin E, Danini D, et al. Diagnosis and management of primary chylous ascites. J Vasc Surg. 2006, 43(6): 1244-1248.


4. Uchinami, M, Morioka K, Doi K, Nakamura T, Yoshida M, Tanaka K. Retroperitoneal laparoscopic management of a lymphocele after abdominal aortic surgery: a case report. Vasc Surg. 2005, 42(3): 552-555.


5. Meinke AH 3rd, Estes NC, Ernst CB. Chylous ascites following abdominal aortic Aneurysmectomy: Management with total parenteral hyperalimentation. Ann Surg. 1979, 190(5): 631-633.


6. Mckenna R, Stevick CA. Chylous ascites following aortic reconstruction. Vasc Surg. 1983, 17: 145-149.


7. Fleischer HL 3rd, Oren JW, Sumner DS. Chylous ascites after abdominal aortic aneurysmectomy: successful management with a peritoneavenous shunt. J Vasc Surg 1987, 6(4): 403-407.


8. Herz J, Shapiro SR, Konrad P, Palmer J. Chylous ascites following retroperitoneal lymphadenectomy: report of two cases with guidelines for diagnosis and treatment. Cancer. 1978, 42(1): 349-352.

9. Lesser GT, Bruno MS, Enselberg K. Chylous ascites: Newer insight and many remaining enigmas. Arch Intern Med. 1970, 125: 1073- 1077.


10. Pabst TS 3rd, McIntyre KE Jr, Schilling JD. Management of chyloperitoneum after abdominal aortic surgery. Am J Surg. 1993, 166(2): 194-198.

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Cite this article: Sven Ross Mathisen . Conservative Management of Chylous Ascites after Elective Abdominal Aortic Aneurysm Surgery. 2017, 1(1): 004.