Successful conservative treatment of chylous ascites as rare intermediate complication after resection of an aboral esophageal carcinoma

Frank Meyer, Guenter Weiss, Zuhir Halloul, Arndt Hribaschek, Karsten Ridwelski, Hans Lippert

Department of Surgery, University Hospital, Magdeburg, Germany

Background: Chylous ascites is an uncommon symptom that needs specific expertise with regard to the diagnostic and therapeutic management.

Methods: We are reporting on an uncommon and exceptional case of a 65-year-old man in whom postoperative chylous ascites was diagnosed using both daily ascites inspection and laboratory investigation. Treatment was initiated according to a previously established protocol, which summarized our own experiences and recommendations from the literature.

Results: The patient showed a prolonged postoperative course after partial esophagectomy of the aboral segment (2-cavity intervention) because of Barrett carcinoma (pT3N1M0G3R0), including lymphadenectomy and esophagogastric anastomosis, which was initially complicated by i) hemorrhage (d2), leading to relaparotomy, ii) prolonged weaning maneuver, and iii) suspicion of chylous ascites characterized by beige and milky effusion out of the abdominal drainage after appendicostoma placement for colonic decompression (d28). Diagnosis was confirmed by laboratory detection of chylomicrons and triglycerides of 4.8 mmol/L. After an observation period of two weeks, total parenteral nutrition (TPN) was initiated for 5 weeks. This resulted in the clearance of ascites (decrease of its amount partially after 5–10 d, completely after 20 d) and final removal of the abdominal drain. There were no further abnormal symptoms or signs.

Conclusions: The established therapeutic concept favoring conservative long-term TPN and avoiding reintervention, which was repeatedly used in rare cases of chylous ascites, is suitable to achieve spontaneous healing of lymphatic leakage by diminishing lymphatic flow due to decreased i) enteral fat absorption and ii) transport along the lymphatic vessels as shown in this exceptional case. To our best knowledge, this is only the sixth case with chylous ascites after esophagectomy reported in the literature.

Keywords: chylous ascites, total parenteral nutrition, esophageal carcinoma, postoperative complication