Vol. 114, December Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1975 by The Williams & Wilkins Co.
CHYLOUS ASCITES FOLLOWING RETROPERITONEAL LYMPHADENECTOMY H. A. BIGLEY, JR. AND 0. W. CHENAULT, JR.
From the Department of Urology, Naval Regional Medical Center, Portsmouth, Virginia
ABSTRACT
A case of postoperative chylous ascites accumulation after retroperitoneal lymph node dissection is reviewed. Although uncommon, this complication is distressing and because of the close proximity of the cisterna chyli to the renal pedicles it may be encountered with any retroperitoneal procedures involving this area. Avoidance of the complication by specific identification and ligation of these structures appears to be the best treatment. Several forms of operative and non-operative therapy have been noted and survival rates in the iatrogenic form of chylous ascites appear to be good based on a limited series of cases. Chylous ascites is an uncommon condition usually occurring as a result of inflammatory, parasitic or neoplastic disease of the lymphatic system of the abdomen or chest. 1 • 3 Even less commonly, this entity occurs as a complication of surgical procedures. •-a Herein we present the third reported occurrence of chylous ascites following retroperitoneal node dissection for testis tumor. 8 • 9 CASE REPORT
G. P., a 24-year-old white man, was referred to our hospital for further treatment after having undergone left radical orchiectomy at another hospital for teratocarcinoma. Physical examination and other studies were negative for metastatic disease, including an excretory urogram (IVP), chest x-ray, bilateral pedal lymphangiogram, 24hour urine for chorionic gonadotropin and serum liver profile. The patient received 2,000 rads of cobalt irradiation to the abdominal and iliac node-bearing areas, after which a bilateral retroperitoneal node dissection was performed. At the termination of the procedure a small amount of milky whitish fluid was seen effluxing from the area adjacent to the left renal pedicle. No definite site of leakage was identified and the wound was closed without difficulty. The nodes were negative for tumor. Abdominal fullness developed 8 days postoperatively and gradually progressed to frank abdominal distension despite normal alimentation. IVP and inferior venacavogram revealed no obstructive lesion, whereas a chest x-ray demonstrated bilaterally elevated diaphragms and a right pleural effusion. The condition worsened after 1 week of expectant observation and an abdominal paraAccepted for publication June 20, 1975. Read at annual meeting of Mid-Atlantic Section, American Urological Association, Hot Springs, Virginia, October 24-26, 1974. The opinions expressed in this paper do not necessarily reflect those of the United States Navy. 948
centesis revealed milky white fluid consistent in appearance with chylous ascites. After drainage of 2,000 cc fluid the catheter was removed. Analysis of this fluid revealed sterile culture, elevated triglycerides, proteins slightly below normal for serum and a specific gravity of 1.034. After partial drainage of the chylous fluid, the distension painstakingly resolved during a 1month period of treatment with diuretics and a low fat diet. Further cobalt irradiation to the abdomen and chest was given subsequently, and the patient has had no recurrence of the ascites or testis tumor during the succeeding 12 months. ETIOLOGY
In 1967 Vasko and Tapper, in a comprehensive review of the subject of chylous ascites, found that the majority of the cases were owing to parasitic, inflammatory or neoplastic disease, intrinsic or extrinsic to the lymphatic system of the chest or abdomen. 1 Postoperative accumulation of chylous ascitic fluid has been reported following pancreaticoduodenectomy, vagotomy, abdominal vascular procedures, radical nephrectomy, celiac ganglionectomy and lymphadenectomy for testis tumor.•· 9 DIAGNOSIS
The patient with chylous ascites may have acute symptoms of peritoneal irritation so that appendicitis or perforated viscus may be the initial diagnostic impression. 1, 10 , 11 However, some authors have questioned the occurrence of so-called chyle peritonitis because of the known antibacterial action of chylous fluid, coupled with the fact that it causes no pain when injected into the peritoneal cavity. 3 The majority of patients in whom chylous ascitic fluid accumulated have a chronic, progressive abdominal enlargement. 1 • 3 , 10 In the reported postoperative cases this occurred approximately 1 week after the operation. 12 • 13 Although x-ray
949
CHYLOUS ASCITES FOLLOWING RETROPERITONEAL LYMPHADENECTOMY
Characteristics of chyle Reference
Specific Gravity
Roy and associates' Ross and associates' Burdette' McCarthy and Organ' Clain' Musgrove 13 Kelley, M. I., Jr. and Butt, H. R.: Gastroenterology, 39: 161, 1960 Present case
1.030 1.007 to 1.002 1.016
pH
Total Lipid (mg.%)
Cholesterol (mg.%)
7
1,750 1,200 to 1,700 200to 3,000 2,721.93 270 to 400 2,610 909 to 3,006
104
169
2,120
106
7.5
1.010 to 1.016 1.034
38
Total Protein (gm.%) 3.8
6.5 to 8.0 1.0 2.61 1.4 to 3.3 1.97 to 4.0 5.5
contrast and serum studies are helpful the definitive diagnosis is made by analyzing a sample of the fluid that is obtained by paracentesis or at laparotomy. Chyle is distinguished from other types of ascitic fluids by a high cholesterol and fat content, high specific gravity, alkaline pH, milky appearance and a non-clotting tendency. With sequestration of this fluid there is a marked loss of proteins, vitamins A, D and K and other nutrients originating in the gastrointestinal tract. The table shows a comparison of chylous fluid characteristics from various reports. ANATOMY
Anatomically chylous ascites results from a rent in the thoracic duct, cisterna chyli or intestinal lymphatic tributaries. The cisterna is a dilated ampullary origin of the thoracic duct lying dorsal and slightly medial to the aorta at the level of the LI and L2 vertebral bodies. It receives 2 paired lumbar tributaries from the respective lower extremities and an intestinal trunk through which the chylous fatty material flows. Thus, the cisterna resides at the level of the renal pedicles and is intimately involved with the primary area of resection of retroperitoneal nodes. The figure shows the anatomical relationships of the cisterna chyli, its tributaries, the great vessels and the kidneys. Unfortunately, up to 50 per cent of the patients do not even have a specific cisterna chyli. 5 Nonetheless, even if the cisterna itself is not present there is a coalescence of lymphatics at this level to form the thoracic duct and this tissue is often included in the node dissection specimen. Because the location of this structure is at the upper margin of the lymph node excision, it would appear that the best method to avoid this complication is to specifically identify, isolate and ligate the cisterna or its tributaries at the level of the renal pedicle. This would preferably be done at the "' beginning of the node dissection so that this area could be observed for significant chylous leakage as the procedure continues. Because of this advantage, we prefer a lymphadenectomy which proceeds from the renal pedicles distally instead of starting at the spermatic cord and progressing cephalad. TREATMENT
Some authors advocate an aggressive approach to postoperative chylous ascites consisting of early
Anatomical drawing shows relationship of cisterna chyli and major lymphatic trunks to great vessels and urinary tract structures.
re-exploration and oversewing of the leaking vessel. 1, 3 • 13 Despite the apparent definitive nature of this approach surgical exploration has been ineffective in locating the site of leakage in a significant number of cases. 3 This attack must be taken in the non-iatrogenic form if the possibility of occult neoplasm exists. Several reports of postoperative chylous ascites have described the efficacy of conservative dietary management. The use of medium-chain triglycerides in the diet may provide a physiologic diversion of fatty substances away from the cisterna chyli since they are transported through the portal vein system, as opposed to the transit of long-chain triglycerides through the lymphatics. 1 • A low fat diet can also accomplish this as demonstrated in our patient. 7 ' 8 A third form of treatment, intravenous reinfusion of chylous material obtained by paracentesis, has been used recently with success in treating this
950
BIGLEY AND CHENAULT
condition. 12 Because fat embolism may be a complication of this technique, reinfusion is regarded as a significantly hazardous form of treatment. Immobilization consisting of bedrest and even body casting has been used in treating this condition. PROGNOSIS
The prognosis for patients with chylous ascites is largely dependent upon the primary etiology of the condition. Vasko and Tapper reported a 43 per cent mortality rate in adults and a 24 per cent mortality rate in children. 1 Chylous ascites owing to iatrogenic rents in the lymphatic system in the absence of other active disease processes appears to have a better survival rate since none of the 11 reported cases, including our own, has died of this condition. REFERENCES
1. Vasko, J. S. and Tapper, R. I.: The surgical significance of chylous ascites. Arch. Surg., 95: 355, 1967. 2. McCarthy, H. H. and Organ, C. A.: Chyloperitoneum. Arch. Surg., 77: 421, 1958. 3. Burdette, W. J.: Management of chylous extravasation. Arch. Surg., 78: 815, 1959.
4. Walker, W.: Chylous ascites following pancreatoduodenectomy. Arch. Surg., 95: 640, 1967. 5. Ikard, R. W.: Iatrogenic chylous ascites. Amer. Surg., 38: 436, 1972. 6. Clain, A.: Chylous ascites following vagotomy. Brit. J. Surg., 58: 312, 1971. 7. Roy, J. B., Abdullian, M. and Walton, K. N.: Chylous ascites. J. Urol., 103: 343, 1970. 8. Ross, G., Jr., Terry, B. E., Thompson, I. M. and Beyer, P.: Urological aspects of chylous ascites. Missouri Med., 68: 312, 1971. 9. Johnson, D. E.: Testicular Tumors. Flushing, New York: Medical Examination Publishing Co., pp. 172-177, 1972. 10. Hoffman, W.: Free chyle in the acute abdomen: so-called chyle peritonitis. Int. Abstr. Surg., 98: 209, 1954. 11. Madding, G. F., McLaughlin, R. F. and McLaughlin, R. F., Jr.: Acute chylous peritonitis. Ann. Surg., 147: 419, 1958. 12. Klippel, A. P. and Hardy, D. A.: Postoperative chylous ascites. Case reports. Missouri Med., 68: 253, 1971. 13. Musgrove, J. E.: Post-vagotomy abdominal chylous fistula. Ann. Surg., 175: 67, 1972. 14. Weinstein, L. D., Scanlon, G. T. and Hersh, T.: Chylous ascites. Management with medium-chain triglycerides and exacerbation by lymphangiography. Amer. J. Dig. Dis., 14: 500, 1969.
THE JOURNAL OF UROLOGY
Copyright© 1975 by The Williams & Wilkins Co.
CHYLOUS ASCITES FOLLOWING RETROPERITONEAL LYMPHADENECTOMY H. A. BIGLEY, JR. AND 0. W. CHENAULT, JR.
From the Department of Urology, Naval Regional Medical Center, Portsmouth, Virginia
ABSTRACT
A case of postoperative chylous ascites accumulation after retroperitoneal lymph node dissection is reviewed. Although uncommon, this complication is distressing and because of the close proximity of the cisterna chyli to the renal pedicles it may be encountered with any retroperitoneal procedures involving this area. Avoidance of the complication by specific identification and ligation of these structures appears to be the best treatment. Several forms of operative and non-operative therapy have been noted and survival rates in the iatrogenic form of chylous ascites appear to be good based on a limited series of cases. Chylous ascites is an uncommon condition usually occurring as a result of inflammatory, parasitic or neoplastic disease of the lymphatic system of the abdomen or chest. 1 • 3 Even less commonly, this entity occurs as a complication of surgical procedures. •-a Herein we present the third reported occurrence of chylous ascites following retroperitoneal node dissection for testis tumor. 8 • 9 CASE REPORT
G. P., a 24-year-old white man, was referred to our hospital for further treatment after having undergone left radical orchiectomy at another hospital for teratocarcinoma. Physical examination and other studies were negative for metastatic disease, including an excretory urogram (IVP), chest x-ray, bilateral pedal lymphangiogram, 24hour urine for chorionic gonadotropin and serum liver profile. The patient received 2,000 rads of cobalt irradiation to the abdominal and iliac node-bearing areas, after which a bilateral retroperitoneal node dissection was performed. At the termination of the procedure a small amount of milky whitish fluid was seen effluxing from the area adjacent to the left renal pedicle. No definite site of leakage was identified and the wound was closed without difficulty. The nodes were negative for tumor. Abdominal fullness developed 8 days postoperatively and gradually progressed to frank abdominal distension despite normal alimentation. IVP and inferior venacavogram revealed no obstructive lesion, whereas a chest x-ray demonstrated bilaterally elevated diaphragms and a right pleural effusion. The condition worsened after 1 week of expectant observation and an abdominal paraAccepted for publication June 20, 1975. Read at annual meeting of Mid-Atlantic Section, American Urological Association, Hot Springs, Virginia, October 24-26, 1974. The opinions expressed in this paper do not necessarily reflect those of the United States Navy. 948
centesis revealed milky white fluid consistent in appearance with chylous ascites. After drainage of 2,000 cc fluid the catheter was removed. Analysis of this fluid revealed sterile culture, elevated triglycerides, proteins slightly below normal for serum and a specific gravity of 1.034. After partial drainage of the chylous fluid, the distension painstakingly resolved during a 1month period of treatment with diuretics and a low fat diet. Further cobalt irradiation to the abdomen and chest was given subsequently, and the patient has had no recurrence of the ascites or testis tumor during the succeeding 12 months. ETIOLOGY
In 1967 Vasko and Tapper, in a comprehensive review of the subject of chylous ascites, found that the majority of the cases were owing to parasitic, inflammatory or neoplastic disease, intrinsic or extrinsic to the lymphatic system of the chest or abdomen. 1 Postoperative accumulation of chylous ascitic fluid has been reported following pancreaticoduodenectomy, vagotomy, abdominal vascular procedures, radical nephrectomy, celiac ganglionectomy and lymphadenectomy for testis tumor.•· 9 DIAGNOSIS
The patient with chylous ascites may have acute symptoms of peritoneal irritation so that appendicitis or perforated viscus may be the initial diagnostic impression. 1, 10 , 11 However, some authors have questioned the occurrence of so-called chyle peritonitis because of the known antibacterial action of chylous fluid, coupled with the fact that it causes no pain when injected into the peritoneal cavity. 3 The majority of patients in whom chylous ascitic fluid accumulated have a chronic, progressive abdominal enlargement. 1 • 3 , 10 In the reported postoperative cases this occurred approximately 1 week after the operation. 12 • 13 Although x-ray
949
CHYLOUS ASCITES FOLLOWING RETROPERITONEAL LYMPHADENECTOMY
Characteristics of chyle Reference
Specific Gravity
Roy and associates' Ross and associates' Burdette' McCarthy and Organ' Clain' Musgrove 13 Kelley, M. I., Jr. and Butt, H. R.: Gastroenterology, 39: 161, 1960 Present case
1.030 1.007 to 1.002 1.016
pH
Total Lipid (mg.%)
Cholesterol (mg.%)
7
1,750 1,200 to 1,700 200to 3,000 2,721.93 270 to 400 2,610 909 to 3,006
104
169
2,120
106
7.5
1.010 to 1.016 1.034
38
Total Protein (gm.%) 3.8
6.5 to 8.0 1.0 2.61 1.4 to 3.3 1.97 to 4.0 5.5
contrast and serum studies are helpful the definitive diagnosis is made by analyzing a sample of the fluid that is obtained by paracentesis or at laparotomy. Chyle is distinguished from other types of ascitic fluids by a high cholesterol and fat content, high specific gravity, alkaline pH, milky appearance and a non-clotting tendency. With sequestration of this fluid there is a marked loss of proteins, vitamins A, D and K and other nutrients originating in the gastrointestinal tract. The table shows a comparison of chylous fluid characteristics from various reports. ANATOMY
Anatomically chylous ascites results from a rent in the thoracic duct, cisterna chyli or intestinal lymphatic tributaries. The cisterna is a dilated ampullary origin of the thoracic duct lying dorsal and slightly medial to the aorta at the level of the LI and L2 vertebral bodies. It receives 2 paired lumbar tributaries from the respective lower extremities and an intestinal trunk through which the chylous fatty material flows. Thus, the cisterna resides at the level of the renal pedicles and is intimately involved with the primary area of resection of retroperitoneal nodes. The figure shows the anatomical relationships of the cisterna chyli, its tributaries, the great vessels and the kidneys. Unfortunately, up to 50 per cent of the patients do not even have a specific cisterna chyli. 5 Nonetheless, even if the cisterna itself is not present there is a coalescence of lymphatics at this level to form the thoracic duct and this tissue is often included in the node dissection specimen. Because the location of this structure is at the upper margin of the lymph node excision, it would appear that the best method to avoid this complication is to specifically identify, isolate and ligate the cisterna or its tributaries at the level of the renal pedicle. This would preferably be done at the "' beginning of the node dissection so that this area could be observed for significant chylous leakage as the procedure continues. Because of this advantage, we prefer a lymphadenectomy which proceeds from the renal pedicles distally instead of starting at the spermatic cord and progressing cephalad. TREATMENT
Some authors advocate an aggressive approach to postoperative chylous ascites consisting of early
Anatomical drawing shows relationship of cisterna chyli and major lymphatic trunks to great vessels and urinary tract structures.
re-exploration and oversewing of the leaking vessel. 1, 3 • 13 Despite the apparent definitive nature of this approach surgical exploration has been ineffective in locating the site of leakage in a significant number of cases. 3 This attack must be taken in the non-iatrogenic form if the possibility of occult neoplasm exists. Several reports of postoperative chylous ascites have described the efficacy of conservative dietary management. The use of medium-chain triglycerides in the diet may provide a physiologic diversion of fatty substances away from the cisterna chyli since they are transported through the portal vein system, as opposed to the transit of long-chain triglycerides through the lymphatics. 1 • A low fat diet can also accomplish this as demonstrated in our patient. 7 ' 8 A third form of treatment, intravenous reinfusion of chylous material obtained by paracentesis, has been used recently with success in treating this
950
BIGLEY AND CHENAULT
condition. 12 Because fat embolism may be a complication of this technique, reinfusion is regarded as a significantly hazardous form of treatment. Immobilization consisting of bedrest and even body casting has been used in treating this condition. PROGNOSIS
The prognosis for patients with chylous ascites is largely dependent upon the primary etiology of the condition. Vasko and Tapper reported a 43 per cent mortality rate in adults and a 24 per cent mortality rate in children. 1 Chylous ascites owing to iatrogenic rents in the lymphatic system in the absence of other active disease processes appears to have a better survival rate since none of the 11 reported cases, including our own, has died of this condition. REFERENCES
1. Vasko, J. S. and Tapper, R. I.: The surgical significance of chylous ascites. Arch. Surg., 95: 355, 1967. 2. McCarthy, H. H. and Organ, C. A.: Chyloperitoneum. Arch. Surg., 77: 421, 1958. 3. Burdette, W. J.: Management of chylous extravasation. Arch. Surg., 78: 815, 1959.
4. Walker, W.: Chylous ascites following pancreatoduodenectomy. Arch. Surg., 95: 640, 1967. 5. Ikard, R. W.: Iatrogenic chylous ascites. Amer. Surg., 38: 436, 1972. 6. Clain, A.: Chylous ascites following vagotomy. Brit. J. Surg., 58: 312, 1971. 7. Roy, J. B., Abdullian, M. and Walton, K. N.: Chylous ascites. J. Urol., 103: 343, 1970. 8. Ross, G., Jr., Terry, B. E., Thompson, I. M. and Beyer, P.: Urological aspects of chylous ascites. Missouri Med., 68: 312, 1971. 9. Johnson, D. E.: Testicular Tumors. Flushing, New York: Medical Examination Publishing Co., pp. 172-177, 1972. 10. Hoffman, W.: Free chyle in the acute abdomen: so-called chyle peritonitis. Int. Abstr. Surg., 98: 209, 1954. 11. Madding, G. F., McLaughlin, R. F. and McLaughlin, R. F., Jr.: Acute chylous peritonitis. Ann. Surg., 147: 419, 1958. 12. Klippel, A. P. and Hardy, D. A.: Postoperative chylous ascites. Case reports. Missouri Med., 68: 253, 1971. 13. Musgrove, J. E.: Post-vagotomy abdominal chylous fistula. Ann. Surg., 175: 67, 1972. 14. Weinstein, L. D., Scanlon, G. T. and Hersh, T.: Chylous ascites. Management with medium-chain triglycerides and exacerbation by lymphangiography. Amer. J. Dig. Dis., 14: 500, 1969.
