Fibrin Glue Application in the Management of Refractory Chylous Ascites in Children

Abstract

The purpose of this retrospective review of the charts of 6 children who underwent surgical treatment of chylous ascites refractory to conservative measures between 1993 and 2006 was to evaluate the efficiency of fibrin glue application for control of lymph leakage. Five children had postoperative chylous ascites (neuroblastoma, 4; cystic lymphangioma, 1) and 1 had a congenital malformation. Surgical exploration revealed large areas of diffuse lymphatic leakage in all of the patients. Lymphatic fistula was not identified intraoperatively in any patient. Ingestion of lipophilic dye in a concentrated fatty meal was not helpful in locating a lymph fistula. Absorbable mesh was used in association with glue application in the last 3 patients treated. Control of ascites was achieved immediately in 2 patients and within 3 weeks in 2 patients. Repeat surgery was required in the remaining 2 patients. The mean follow-up time was 4.3 years. One patient died of tumor recurrence 12 months after surgical treatment without relapse of the ascites. Two mild late recurrences were observed at 6 and 11 months after surgery and were managed conservatively. The findings of this study show that fibrin glue application on absorbable mesh after dissection of the leakage zones is easy, safe, and effective. We recommend that surgery with glue application be repeated until control of ascites is achieved. We suggest fibrin glue application as a preventive measure against postoperative chylous ascites.

Mesenteric lymphatic ligation in the prevention of chylous fistulae in abdominal neuroblastoma surgery

“…Laparotomy and ligation of chylous fistulae have been reported infrequently for refractory cases [2,7]. Intraoperative topical application of fibrin sealants [5,8] has been reported with variable successes, but we have not found its usefulness as a prophylaxis in a few of our earlier patients. Less invasive treatment with peritoneo-venous shunts has also been reported [6,9,10].…”

“…The former includes medium chain triglyceride (MCT) diet or total bowel rest, total parenteral nutrition (TPN), somatostatin or its analog, and likely require prolonged hospitalization and delay in subsequent chemotherapy [1,2,4]. There is a tendency to avoid surgical treatment in postoperative chylous fistulae because of the challenges faced with repeat laparotomies and the potential failure to identify and rectify the chylous fistulae [5].…”

A rare cause of acute abdomen: Chylous ascites

“…This type of diet would be more effective, especially if the leakage is secondary to the intestinal lymphatic system. Parenteral nutrition and octreotide treatment can substantially reduce chylous ascites resulting in low lymphatic flow (7,10,11).…”

Chylous Ascites in HIV/TB Co-Infections: Case Report, Challenges of Management in a Resource-Poor Setting and Literature Review

“…This may be by direct ligation of the leaking lymphatics with or without use of fibrin glue and absorbable mesh or by establishing a peritoneovenous shunt. [19,20] Peritoneovenous shunting is only used in a small group of patients with rapid accumulation of CA. This avoids nutritional depletion associated with repeated paracentesis as the fluid is recirculated.…”