Chylous Ascites and Chylothorax after Pancreaticoduodenectomy: Case Report and Literature Review

    

    

    Figure 1:  Post-operative CT Chest, Abdomen Pelvis. CT imaging A-D
illustrating post-operative chyle leak. A) Representing right pleural effusion.
B&C) Representing chylous ascites. D) Peripancreatic fluid collection.
    
    

The patient underwent percutaneous drainage of the abdominal fluid collection and thoracentesis. Fluid triglyceride was 907 mg/ dL confirming chyle leak with chylous ascites and chylothorax. A wound manager was placed over the opened midline incision to control continued drainage. Daily output from the abdominal drain and wound manager ranged from 1-3.8L. Therefore, the patient was allowed nothing per os, treated with octreotide 100mcg SQ every 8 hours, and administered total parenteral nutrition. Over the next 7 days, drain output tapered down and transitioned in character from chylous to clear ascitic fluid with a normal triglyceride level, likely related to the patient’s underlying alcoholic cirrhosis. Eventually the output decreased to 325ml over 24 hours on postoperative day 17, at which point an oral diet was reintroduced. Ultimately, the drain was removed and the patient was discharged home on postoperative day 26 tolerating a regular diet.

Discussion

Chyle leak is a complication more often associated with esophagectomy, radical neck dissection, pneumonectomy or extensive retroperitoneal lymphadenectomy [1]. Following pancreatic resection, chyle leak occurs with a frequency of approximately 1.3 % [2]. When chyle leaks develop, they are often associated with protracted clinical courses and poorer long term survival [3]. Reported risk factors for chyle leak following pancreatic resection include female gender, history of chronic pancreatitis, extensive lymphadenectomy as well as formation of portal or mesenteric thrombosis [4]. The most common presentation of chyle leak is abdominal distension after the patient has been introduced to a diet [5]. Chyle leaks often present on post-operative days 5-9 and are frequently incited by initiation of enteral feeding [6]. In addition to abdominal distention following introduction of enteral feeding, a classical feature of chylous ascites is milky discharge from the incision site. The diagnosis of chylous ascites or chylothorax is confirmed by a fluid triglyceride level of 110 mg/dL or greater. Sampling the fluid from a suspected leak is generally recognized as a more reliable means of diagnosis than imaging such as CT [7]. While CT is not strongly endorsed as a means of diagnosing chyle leak, lymphiangiography can be used to effectively localize and characterize a leak [8]. In addition to its diagnostic qualities, there is evidence from small case studies that lymphoangiography can also be therapeutic; resulting in lymphatic leak closure following this procedure [9].

Ideally, management of a chyle leak should gradually increase in invasiveness; beginning with dietary restrictions, then radiological interventions and, lastly, surgical interventions for those patients refractory to more conservative management (Figure 2).

    

    

    Figure 2:  Algorithm for Diagnosis and Management of Chylous Ascites.