Postoperative Lymphorrhagia- a Possible Complication Following Cephalic Duodenopancreatectomy

Abstract

Surgery associated with lymphadenectomy may sometimes result in a lymphorrhagia, which usually resolves spontaneously within a few days, sometimes becoming a refractory complication to the treatment. In the case of large flows, particular attention should be paid to hydro-electrolytic and protein losses. We present the case of a patient with persistent lymphorrhagia after a cephalic duodenopancreatectomy for a pancreatic head tumor. From the 5th postoperative day, the patient had a milky-like secretion on the subhepatic drainage tube. The discharge rate was variable, between 500 and 1500 ml per day, requiring parenteral administration of amino acids, plasma and electrolyte solutions. The postoperative progression was slowly favorable, with the patient discharge on the 25th day following surgery. There are several treatment options for a lymphorrhagia following an extended lymphadenectomy, from intensive parenteral therapy to peritoneal-venous shunt or ligation of the lymphatic vessel responsible for the production of lymphorrhagia. In this case the conservative treatment had a favorable result.

Chylous Ascites, Unusual Association with Ductal Pancreatic Adenocarcinoma with Plasmacytoid Morphology: A Case Report and Literature Review

“…In developed, western countries, abdominal tumors, cirrhosis, and iatrogenic lymph vessels disruption during surgery accounts for more than half of chylous ascites, while in developing countries, the most frequent etiologies responsi-ble for this condition are infectious diseases like tuberculosis and filariasis. 1,2 The main mechanisms of acquired chylous ascites are the following ones: traumatic disruption of thoracic duct, obstruction of lymphatic flow, caused by infectious agents or tumor cells, fibrosis of the lymph vessels wall, in patients with autoimmune diseases or after radiotherapy, or increased lymph fluid production, such in cirrhosis or cardiovascular diseases. 3,6,[8][9][10] Although rare, malignancies such as lymphomas (30% of all reported cases), Kaposi sarcoma, leukemias, neuroendocrine tumors or adenocarcinomas of the gastrointestinal tract, and carcinomas of lung and endometrium were described to be the possible causes of chylous ascites.…”

“…11 Total parenteral nutrition associated with diuretics, medium chain triglycerides, and removal of the drainage tube was also suggested. 2,12 Even though it is not the most common cause of chylous ascites, PDAC can cause it via lymphangiosis carcinomatosa, respectively obstruction and disruption of lymphatic channels flow. Representing one of the most lethal tumors worldwide, PDAC is the 12th most common encountered cancer worldwide, with an incidence of 4.2 per 100,000 and over 330,400 deaths per year.…”

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Chylous ascites, also known as chyloperitoneum or lymphorrhagia, is a rare lesion of adults, with a reported incidence of 1:20,500, which is defined by the presence of a milky and lipid-rich fluid in the peritoneal cavity. [1][2][3][4][5][6] Lymphatic fluid is characterized by thick consistency, cell count >500/mL, with lymphocytic predominance, total protein level between 2.5 and 7.0 g/dL, with serum to ascites albumin gradient (SAAG) less than 1.1 g/dL, lactate dehydrogenase (LDH) between 110 and 200 IU/L, glucose level >100 mg/dL, and triglyceride level in ascetic fluid >110 mg/dL. 1,2

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“…Chylous ascites, also known as chyloperitoneum or lymphorrhagia, is a rare lesion of adults, with a reported incidence of 1:20,500, which is defined by the presence of a milky and lipid-rich fluid in the peritoneal cavity. 1 2 3 4 5 6 …”

“…Lymphatic fluid is characterized by thick consistency, cell count >500/mL, with lymphocytic predominance, total protein level between 2.5 and 7.0 g/dL, with serum to ascites albumin gradient (SAAG) less than 1.1 g/dL, lactate dehydrogenase (LDH) between 110 and 200 IU/L, glucose level >100 mg/dL, and triglyceride level in ascetic fluid >110 mg/dL. 1 2 …”