Abstract
Chyle leak is a rare complication in colorectal surgery. It occurs due to disruption of the lymphatic drainage network in the abdomen or retroperitoneum. We describe the first reported case of chyle leak following total colectomy for inflammatory bowel disease. Our patient underwent total colectomy for severe ulcerative colitis not responsive to medical treatment. Four days postoperatively, a milky fluid was noted in the drainage bag. Analysis of the fluid confirmed chyle. The patient remained well and was successfully managed conservatively with a fat-free elemental diet and was discharged from hospital on day 12 postoperatively. A review of the literature suggests that conservative management with dietary modification is a common and effective management strategy; however, medical and surgical options exist for refractory cases.
Keywords: Ulcerative colitis, Chylous ascites, Chyle leak, Elemental diet, Total colectomy
Background
Chyle leak is a rare complication of abdominal surgery. It is likely related to iatrogenic trauma to lymphatic vessels and associated tributaries. Minor leaks may be asymptomatic; however, significant loss of chyle into the thoracic or abdominal cavity can predispose to malnutrition, severe thoracic or peritoneal infection and even death.1 The true incidence is unknown, and there is currently no consensus regarding management or follow up.
In colorectal surgery, chyle leak is extremely unusual. Isolated reports and case series have identified retroperitoneal dissection as a risk factor for chyle leak during colorectal resection for cancer, which can often require extensive lymphadenectomy.2–5 However, there have been no reported cases following resection for benign pathology. We report a case of chyle leak following emergency total colectomy for ulcerative colitis, and review the literature on chyle leak after colorectal surgery.
Case history
A 32-year-old woman with a background of ulcerative colitis presented to the accident and emergency department with severe abdominal pain, increased bowel motions (>20 times per day), nocturnal diarrhoea and passage of blood per rectum. Following assessment by the gastroenterology team, it was decided that she had failed medical management and needed an emergency total colectomy.
The following day, she underwent a laparoscopic total colectomy and formation of end ileostomy. Lateral-to-medial mobilisation of bowel was performed using a combination of blunt and electrodissection using the Thunderbeat (Olympus America). Ileocolic, middle colic and inferior mesenteric vessels were clipped using Haem-O-Lok’s (Weck, Teleflex, USA) close to the colon. Complete mesocolic excision was not done due to benign disease. Following colon extraction, relook laparoscopy confirmed adequate haemostasis and correct configuration of the ileostomy. As part of our standard practice, a pelvic drain was inserted through the suprapubic port.
On postoperative day four, the drainage bag was noted to contain a white milky fluid suspicious of a chyle leak (Figure 1). Fluid analysis identified high lipid content (cholesterol 2.24mmol/l, triglyceride 20.8mmol/l, glucose 4.7mmol/l), confirming diagnosis of a chyle leak. Computed tomography (CT) scan of the abdomen and pelvis demonstrated no evidence of collection.
Figure 1 .
Pelvic drain, postoperative day 4
As the chyle leak was <250ml per day, the patient was managed conservatively with a fat-free diet, and drain output gradually reduced. She was discharged on day 12 following surgery, with drain in situ (clamped). This was removed 1 week later after cessation of drainage. No further complications were reported.
Discussion
Chylous ascites following colon surgery is a rare occurrence, with an estimated incidence between 1.0% and 6.6% (Table 1).5–9 Iatrogenic chyle leak is thought to be due to intraoperative trauma to lymphatic vessels in the retroperitoneum or bowel mesentery, which can be difficult to identify and ligate intraoperatively. Colorectal procedures involving retroperitoneal dissection or substantial lymphatic resection are therefore considered greater risk.5 There may also be additional contribution from lymphatic obstruction secondary to tumour deposits downstream in patients with metastatic disease. To our knowledge, there have been no reported cases following colorectal surgery for inflammatory bowel disease.
Table 1 .
Summary of studies reporting chyle leak following colorectal surgery
| Study | Pathology | Operation details | Lymph node dissection | Patients with chyle ascites | Incidence | POD chyle leak identified | POD drain removal | Management |
|---|---|---|---|---|---|---|---|---|
| Author, Year | (n) | Level, (n) | n (total) | % | Mean | Mean | (n) | |
| Nishigori et al 20126 | Colorectal cancer | Right hemicolectomy (5) | D2 (2), D3 (7) | 9 | 1.0 | 5.2 | 10.3 | Low-fat diet (1), intestinal fasting (6), nil (2) |
| Sigmoid colectomy (1) | ||||||||
| Low anterior resection (1) | ||||||||
| Hartmanns (2) | ||||||||
| Matsuda et al 20137 | Colorectal cancer | Limited colectomy (9) | D3 (9) | 9 | 6.5 | 4.0 | 10.1 | Low-fat diet (1), intestinal fasting (8) |
| Baek et al 20138 | Colorectal cancer | Right hemicolectomy (16) | D3 (48) | 48 | 6.6 | 4.1 | 7.4 | Conservative management (39), intestinal fasting (8), Ocreotride (1) |
| Transverse hemicolectomy (2) | ||||||||
| Left hemicolectomy (2) | ||||||||
| Total colectomy (1) | ||||||||
| Rectal resection (26) | ||||||||
| Giovannini et al 20052 | Colorectal cancer | Anterior resection (1) | D3 (1) | 1 | NR | 6.0 | 28.0 | Intestinal fasting, TPN, ocreotride and somatostatin (1) |
| Chan et al 20063 | Colorectal cancer | Anterior resection (1) | NR | 1 | NR | N/A | N/A | Surgery (1) |
| Nakayama et al 20124 | Colorectal cancer | Low anterior resection (1) | NR | 1 | NR | N/A | N/A | Low-fat diet (1) |
| Isik et al 20159 | Colorectal cancer | Subtotal colectomy + hysterectomy (1) | NR | 4 | 1.5 | NR | NR | Fat-free diet and TPN (4) |
| Right hemicolectomy (1) | ||||||||
| Loop colostomy takedown (1) | ||||||||
| Anterior resection + gastrectomy (1) | ||||||||
| Lu et al 20125 | Colorectal cancer | Right hemicolectomy (16) | NA | 46 | 3.6 | NA | NA | NA |
| Left hemicolectomy (7) | ||||||||
| Anterior resection (23) | ||||||||
| Ha et al 201510 | Colorectal cancer | Anterior resection (1) | D2 (1) | 1 | NA | 14.0 | NA | Low-fat diet + median chain triglycerides (failed), TPN + somatostatin injections (failed), Surgical ligation of fistula |
NA = not available; NR = not recorded; POD = post-operative days; TPN = total parenteral nutrition
Here, we present a case of a chyle leak following total colectomy for refractory ulcerative colitis. In our practice, the pelvic drain inserted intraoperatively afforded both diagnostic and treatment benefits. Ascitic fluid assay provided a rapid diagnostic test for chyle leak (defined as the presence of chylomicrons and a triglyceride level greater than 6.1mmol/l (normal <1.7mmol/l)),11 while ongoing drainage reduced the risk of ascites. The presence of chyle on day four postoperatively in the drain is in keeping with other reports in the literature (Table 1),7,8 and corresponds to the recommencement of oral intake.
Management of our patient consisted of a fat-free elemental diet to reduce lymphatic output, along with passive drainage of chyle through the pelvic drain. Similar conservative strategies have been reported widely in the literature with good results (Table 1).4,6,8,9,12 In most reported cases, drain output gradually reduced to negligible amounts by approximately day 10 postprocedure,6,7 when it can be safely removed. Cases refractory to conservative management may benefit from using a step-up algorithmic approach to reducing lymphatic outflow,12 including medium chain triglyceride diet (bypasses lymphatics), somatostatin analogues and total parenteral nutrition (TPN) with bowel rest;2,8,9 however, the overall evidence basis is limited. Surgical intervention should be seen as a last resort, involving ligation, clipping or coagulation of the leaking lymphatic vessels.10
There have been several case series describing chyle leak following bowel resection for colorectal cancer (Table 1). In colorectal cancer surgery, complete mesocolic excision (CME) is widely practiced as gold standard to ensure cancer clearance.13–15 The associated dissection in CME risks causing trauma to adjacent lymphatic vessels, which can precipitate a chyle leak. However, in benign conditions, CME is not required. In our case, total colectomy was performed for IBD, and did not require CME. The finding of chylous ascites postoperatively in this case therefore illustrates possible potential risk of lymphatic trauma and subsequent chyle leak despite close mesenteric dissection.
Conclusion
We describe the first reported case of chyle leak following total colectomy for inflammatory bowel disease. This case highlights the potential risk of lymphatic trauma even with close mesenteric dissection. Conservative measures should be used in the first instance for treatment, followed by more invasive strategies in refractory cases.
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