Milk-Based Test as a Preventive Method for Chylous Ascites following Pancreatic Resection

Abstract

Background/Purpose: The incidence and natural history of postoperative chylous ascites are not well understood. This complication causes malnutrition and prolonged hospital stay. We investigated our institution’s experience involving chylous ascites, especially following pancreatectomy. Additionally, we designed a new intraoperative method dubbed the ‘milk test’ for preventing chylous ascites. Methods: Five cases of chylous ascites following pancreatectomy from April 2001 through March 2004 were studied retrospectively. The milk test was carried out prospectively. Such rates as positivity and incidence of ascites were examined. Results: Of 65 cases (40 pancreatoduodenectomy; 25 distal pancreatectomy), 5 (7.7%) developed chylous ascites following pancreatic resection. All cases underwent octreotide and total parenteral nutrition treatment. From April 2004 through March 2009, the milk test was used in 104 cases. Surgical procedures comprised pancreatoduodenectomy (n = 78) and distal pancreatectomy (n = 23). Of these cases, 23 (22.1%) tested positive. No significant difference in positive rates was observed between the procedures and diseases. After initiation of the milk test, chylous ascites incidence decreased from 7.7 to 2.9%. Conclusions: For chylous ascites, octreotide and total parenteral nutrition treatments are useful. However, the milk test was found to be a safe and effective method for prevention of chylous ascites following pancreatectomy.

Treatment options for chylous ascites after major abdominal surgery: a systematic review

“…Therefore optimal placement of drainage tubes is a prerequisite for postoperative detection of chylous ascites. After thorough evaluation of the literature, a clinically significant postoperative chylous ascites is best defined as the appearance of milky (1, 5,6,[8][9][10][11][12][13][14][15]27), non-purulent (8,14) fluid in the abdominal cavity or in drainage tubes, with a triglyceride level >110 mg/dl (5,8,12,14,15) and a daily minimum volume of 200 ml (8,15,18). A microbiological culture and a white blood cell count are indispensable to rule out infection.…”

“…Incidence of chylous ascites ranged from 0.17% to 2% in gynecological pelvic surgery (3)(4)(5), 1.0% to 6.6% in colorectal surgery (6-8), 4.7% in hepatic surgery including liver transplantation (9), 3.8% to 5.1% in nephrectomy (10,11), and 1.0% to 11% in pancreatic surgery (1, [12][13][14][15][16][17][18][19]. The incidence of chylous ascites in patients with abdominal drainage after pancreatic surgery did not differ significantly from those patients without drainage (20).…”

“…The definition of the minimum daily volume of chylous ascites varied from 100ml (12) to 600ml (16), but most authors define 200ml /24h as the lower limit (8,15,18). Laboratory findings typical for chylous ascites were amylase (12,15,16)-and bilirubin-poor (16), chylomicron-rich (16) drainage fluid with a triglyceride concentration >110 mg/dl (5,8,12,14,15) or >1.2 mmol/l (1, 27). Other authors used a minimum of 150 mg/dl (11) or 200 mg/dl (17) in triglycerides.…”

“…Therefore, routine use of a feeding jejunostomy cannot be recommended and a fat containing-diet prior to the 4 th postoperative day should be avoided. An intraoperative milk-test with insertion of 100ml milk via a nasogastric tube reduces the incidence of postoperative chylous ascites (14). Though this is not a standard procedure, such a test may be used in cases of increased risk for chylous ascites.…”

“…chylous ascites was mainly based on clinical parameters by a large number of authors:Concurrent with the beginning of enteral feeding(9,13,27) the appearance of milky (1,5,6,[8][9][10][11][12][13][14][15]27), non-purulent(8,14) fluid in the drainage tubes was characteristic for postoperative chylous ascites.…”