Contemporary Management of Chylous Ascites after Retroperitoneal Surgery: Development of an Evidence-Based Treatment Algorithm

Abstract

Purpose:Chylous ascites (CA) is an uncommon complication that occurs from traumatic disruption of lymphatic channels after retroperitoneal surgery. The purpose of this study was to generate an evidence-based management strategy for CA by reviewing the current literature and available treatment modalities.Materials and Methods:A MEDLINE® literature review was performed for “chylous ascites.” Individual patient data were extracted from case series and reports to create an efficacy analysis. Treatment modality, drain output, time to escalation of care and time to resolution were recorded. The efficacy analysis was utilized to generate a data-driven treatment algorithm.Results:The literature review yielded 1,953 articles, from which 146 studies contributed data for 523 patients. The efficacy analysis included 245 patients, 168 (69%) of whom were managed successfully with conservative management (CM), at a median time to resolution of 11 days. Forty-eight patients underwent lymphangiography±embolization after CM, with a success rate of 85%. Thirty-one (12%) patients underwent surgical exploration. When treating CA, the patients who underwent stepwise management with CM followed by lymphangiography if CM failed experienced a resolution rate of 96.7%. An evidence-based treatment algorithm was created to guide treatment selection and duration of therapy before escalating to additional forms of therapy.Conclusions:In this report, we describe the largest conglomeration of iatrogenic CA cases from a literature review (523 cases) and efficacy analysis (245 cases), and created the first evidence-based treatment algorithm for this condition. Treatment success is substantial when using a stepwise combination of CM followed by lymphangiography±embolization.

Post-operative chyle leak following nephrectomy: Inference from tertiary care center and review of literature

“…The combination of an MCT diet, somatostatin analog and TPN comprises the conservative management (CM) of CL. 11 As reported in the literature, most patients with CL at any site in the body respond to this management.…”

“…Rose et al 11 developed an evidence-based treatment algorithm for the management of CA after surgery. In their review, they noted that prolonged treatment with CM increased patient morbidity and length of stay.…”

Prevention, incidence, and risk factors of chyle leak after radical nephrectomy and thrombectomy

“…Postoperative CL is a rare complication that occurs after urological surgeries, mainly in lymph node dissection for testicular cancer or renal cell carcinoma 3,6 . The incidence of CL in urological surgeries ranges from 0.77% to 15% depending on the type of surgery and the diagnostic criteria for CL 3,8 .…”

“…Therefore, we analyzed patients with CL after RNAT in a large medical center to define the incidence and risk factors of CL after RNAT and determine its clinical implications. The pathogenesis of postoperative CL involves the disruption of the cisterna chyli or the main lymphatic vessels, 3,6,16 leading to the leakage of chyle fluid into the abdominal cavity. In addition, spontaneous small leakage of lymphatic vessels also contributes.…”

“…Radical nephrectomy and thrombectomy (RNAT) is the standard surgical treatment for renal cell carcinoma (RCC) with tumor thrombus (TT) invading the IVC. RNAT increases the 5‐year tumor‐specific survival rate to 40% to 65%, 10 but it also increases the risk of CL compared to radical nephrectomy alone considering the anatomical proximity of the IVC to the lymphatic ducts or cisterna chyli 6 . However, only few studies have demonstrated the incidence, prevention, and risk factors of CL and its correlation with prolonged hospitalization in patients with RCC and TT 3 .…”