Chylous ascites in colorectal surgery: A systematic review

Abstract

BACKGROUND Chylous ascites is a rare complication in colorectal surgery with limited evidence. AIM To systematically review all available evidence to describe the incidence, clinical presentation, risk factors and management strategies. METHODS The systematic review was performed through PubMed, MEDLINE, EMBASE and Cochrane and cross-checked up to November 2020. The data collated included: Demographics, indications (benign vs malignant), site of disease, surgical approach, extent of lymphadenectomy, day to and method of diagnosis of chylous ascites and management strategies. RESULTS A total of 28 studies were included in the final analysis (426 cases). Patient age ranged from 31 to 89 years. All except one case were performed for malignancy. Of the 426 cases, 195 were right-colonic, 121 left-colonic, 103 pelvic surgeries and 7 others. The majority were diagnosed during the same inpatient stay by recognition of typical drain appearance and increased volume. Three cases were diagnosed during outpatient visits with increased abdominal distention and subsequently underwent paracentesis. Most cases were managed successfully non-operatively (fasting with prolonged drainage, total parenteral nutrition, somatostatin analogues or a combination of these). Only three cases required surgical intervention after failing conservative management and subsequently resolved completely. Risk factors identified include: Right-colonic surgery/ tumour location, extent of lymphadenectomy and number of lymph nodes harvested. CONCLUSION Chylous ascites after colorectal surgery is a relatively rare complication. Whilst the majority of cases resolved without surgical intervention, preventative measures should be undertaken such as meticulous dissection and clipping of lymphatics during lymphadenectomy to prevent morbidity.

Incomplete lymphatic sealing around the inferior mesenteric artery is a risk factor for chylous ascites in robotic rectal cancer surgery

“…A systematic review concluded that a chylous ascites diagnosis is often based on appearance in the drainage tube, and the inclusion of drainage volume (≥200 mL/d) and triglyceride levels (≥110 mg/ dL) is controversial because of a lack of criteria. 9 Determining the criteria for chylous ascites will be an important aim in future studies.…”

“…Previous reports have shown that risk factors for chylous ascites in colorectal surgery include right-sided colon cancer, the number of dissected lymph nodes, and a shorter operative time. [7][8][9][14][15][16] However, few studies have focused only on left-sided colon and rectal lesions, and none have examined the relationship between lymphatic sealing around the IMA and chylous ascites.…”

“…What is known is that the area around the IMA is rich in lymphatic vessels and prone to ascites leakage from lymphatic vessel damage. [9][10][11][12] Lymphatic vessels may not be adequately sealed using MS, 6,7,17 whereas BVSD and vascular clips could prevent chylous ascites. 6,7,23 One in vivo study comparing burst pressure after thoracic duct sealing using MS, BVSD, and UCS identified BVSD and UCS as superior.…”

“…29,30 Right-sided colon cancer has been suggested as a potential risk factor for chylous ascites, even more so than rectal cancer surgery. 9 A current concern is that chylous ascites may arise more frequently in RS for colon cancer than in RS for rectal cancer. In future robotic colorectal surgeries, it thus would be more important to be aware of lymphatic sealing and to use bipolar forceps, BVSD, UCS, and vascular clips in addition to MS during lymphatic dissection to prevent postoperative chylous ascites.…”

“…Although chylous ascites after colorectal cancer surgery is rare and curable with conservative treatment in most instances, [7][8][9] some cases after left-sided colon and rectal cancer may be difficult to manage nonoperatively and require surgery. [10][11][12][13] Results of some retrospective studies have highlighted potential risk factors for chylous ascites in colorectal cancer surgery, [7][8][9][14][15][16] but the association between chylous ascites and RS in rectal cancer remains controversial, addressed only in one recent report. 17 The purpose of the present study thus was to evaluate the incidence of chylous ascites in RS for rectal cancer and investigate the influence of chylous ascites on patients.…”