Alexandra Argiroff, MD, Chaya Schwaartz, MD, Melissa Chang Tang, MD, Brian Jacob, MD, FACS, Mark A Reiner, MD, FACS, Tony Vine, MD, FACS, L. Brian Katz, MD, FACS. Mount Sinai Medical Center
We present a case of successful laparoscopic management of chylous ascites following bariatric surgery. Chylous ascites is an exceedingly rare and potentially devastating complication of bariatric and foregut surgery.
Our patient had a stomach intestinal pyolorus-sparing surgery for weight loss at another hospital 3 months prior to her presentation. She had 10.5L of what ended up being chylous ascites drained from her abdomen on initial laparoscopic exploration.
After failed attempt at non-operative management of bowel rest, TPN and octreotide, her albumin dropped to 1.4g/dL. She was taken for another laparoscopic exploration that lasted about an hour, and no leak was identified.
In the following week, she had a lymphangiogram that also did not identify a source of her chylous ascites. She did not improve over the course of 4 weeks in the hospital, and ultimately developed cholecystitis.
She was taken to the OR again for diagnostic laparoscopy and cholecystectomy. A cream cocktail of cream, mineral oil, charcoal and methylene blue was administered via a nasogastric tube immediately after induction of anesthesia. After dissection of the hiatus and exploration for 30 minutes, no leak was found, and a challenging cholecystectomy was performed.
Because of the difficulty of the cholecystectomy, it was another 2 hours before we looked at the hiatus again. At that time, we saw copious white chyle pouring out from a lymphatic duct, likely the thoracic duct, on the medial aspect of the left crus. This was clearly the source of her problem.
We ligated the lymphatic duct with two figure-of-eight sutures using 2-0 silk on an SH needle. The chyle stopped leaking and a drain was left. She was able to tolerated diet with minimal serous output from her JP drain, and was discharged home 3 days later. At her 3 month follow up, she had appropriate weight loss from her bariatric surgery, and her albumin had increased to 3.7g/dL.
There are only a few case reports of chylous ascites after laparoscopic adjustable gastric band placement, Nissen fundoplication and laparoscopic Roux-en-Y gastric bypass. It is difficult to diagnose and locate the source.
Administering a cream cocktail orally after induction of anesthesia was helpful for identifying the location of the lymphatic leak, and a waiting time of at least 2 hours was crucial in this case. Lymphatic duct injuries can be managed safely with laparoscopic surgery.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 80168
Program Number: V095
Presentation Session: Bariatric Video Session
Presentation Type: Video