Chylous ascites in the setting of internal hernia: a reassuring sign

Abstract

Background Chylous ascites is often reported in cases with lymphatic obstruction or after lymphatic injuries such as intraabdominal malignancies or lymphadenectomies. However, chylous ascites is also frequently encountered in operations for internal hernias. We sought to characterize the frequency and conditions when chylous ascites is encountered in general surgery patients. MethodsData from patients who underwent operations for CPT codes related to open and laparoscopic abdominal and gastrointestinal surgery in our tertiary hospital from 2010 to 2019 were reviewed. Patients with the postoperative diagnosis of internal hernia were identified and categorized into three groups: Internal Hernia with chylous ascites, non-chylous ascites, and no ascites. Demographics, prior surgical history, CT findings, source of internal hernia, open or laparoscopic surgery, and preoperative labs were recorded and compared. ResultsFifty-six patients were found to have internal hernias and were included in our study. 80.3% were female and 86% had a previous Roux-en-Y gastric bypass procedure (RYGBP).Laparoscopy was the main approach for all groups. Ascites was present in 46% of the cases. Specifically, chylous ascites was observed in 27% of the total operations and was exclusively (100%) found in patients with gastric-bypass history. Furthermore, it was more commonly associated with Petersen's defect (p<0.001), while the non-chylous fluid group was associated with herniation through the mesenteric defect (p<0.001).Conclusions Chylous ascites is a common finding during internal hernia operations. Unlike other more morbid conditions, identification of chylous ascites during an internal hernia operation appears innocuous. However, in the context of a patient with a history of RYGBP, the presence of chylous fluid signifies the associated small bowel obstruction is likely related to an internal hernia through a patent Petersen's defect.

Lymphatic Chyle Duct Injury and Identification During Laparoscopic Sleeve Gastrectomy Preventing Postoperative Chylous Ascites

“…ChP has also been reported to occur after bariatric surgeries, mostly due to internal hernias, especially after RYGB. Sakran et al [ 13 ] for instance had undergone a systematic review of the literature and identified 38 patients from 22 case reports and one cohort study [ 14 ] with postoperative ChP. In his study, Sakran et al concluded that most of the cases were due to internal hernias after RYGB, and rarely due to iatrogenic CDI.…”

Rare Combination of Chyloperitoneum Secondary to Primary Small-Bowel Volvulus

“…Our case is an unusual combination, because the chylous ascites was caused by a rare primary small bowel volvulus in an adult. The literature for mesenteric lymphatic infiltration and small bowel volvulus is scarce and focuses primarily on paediatric cases or patients with a surgery or intra-abdominal radiotherapy past [5][6][7][8][9]. Only a few case reports and small case series [10][11][12] describe this unique combination.…”

“…Athanasiadis et al [9] proposed that the presence of chylous ascites with intestinal strangulation due to internal hernia is an innocuous finding. Hayama et al [12] theorize that chylous ascites in a patient with volvulus or internal hernia is innocuous and it may reflect the patency of the mesenteric vessels.…”

The application of a medium-chain fatty diet and enteral nutrition in post-operative chylous leakage: analysis of 63 patients

“…The MCT diet had a greater effect on the reduction of chylous flow in the digestive tract and did not stop lymphatic flow production. Hence, although CL was better controlled in patients with CL after thyroid surgery, lymph leaks may be less likely to heal relative to other sites of surgery ( 33 ). This may explain the longer LOS for patients with CL after thyroid surgery.…”

“…CL is distinguished from lymphatic leakage by the pathological leakage of chylomicron rather than pure lymphocytes from broken lymphatic vessels after digestion and absorption through the gastrointestinal tract. Therefore, drainage fluid appears usually milky white or even pink ( 2 , 33 ). Whereas, short- and medium-chain triglycerides (MCTs) enter the liver directly through the hepatic portal vein ( 34 ).…”