Spontaneous healing of retroperitoneal chylous leakage following anterior lumbar spinal surgery: a case report and literature review

Abstract

Cisterna chyli is prone to injury in any retroperitoneal surgery. However, retroperitoneal chylous leakage is a rare complication after anterior spinal surgery. To the best of our knowledge, only ten cases have been reported in the English literature. We present a case of a 49-year-old man who had lumbar metastasis and associated radiculopathy. He had transient retroperitoneal chylous leakage after anterior tumor decompression, interbody bony fusion, and instrumental fixation from L2 to L4. The leakage stopped spontaneously after we temporarily clamped the drain tube. Intraperitoneal ascites accumulation developed thereafter due to nutritional loss and impaired hepatic reserves. We gathered ten reported cases of chylous leak after anterior thoracolumbar or lumbar spinal surgery, and categorized all these cases into two groups, depending on the integrity of diaphragm. Six patients received anterior spinal surgery without diaphragm splitting. Postoperative chylous leak stopped after conservative treatment. Another five cases received diaphragm splitting in the interim of anterior spinal surgery. Chylous leakage stopped spontaneously in four patients. The remaining one had a chylothorax secondary to postop chyloretroperitoneum. It was resolved only after surgical intervention. In view of these cases, all the chylous leakage could be spontaneously closed without complications, except for one who had a secondary chylothorax and required thoracic duct ligation and chemopleurodesis. We conclude that intraoperative diaphragm splitting or incision does not increase the risk of secondary chylothorax if it was closed tightly at the end of the surgery and the chest tube drainage properly done.

A review of the postoperative lymphatic leakage

“…50% to 90% of lymph fluid in cisterna chyli and thoracic duct comes from intestines and liver. Fasting before operation may decrease lymphatic flow less than 1 ml/min dramatically, while it may increase to more than 200 ml/min after a normal diet recovers [ 11 , 12 ]. The amount of the lymphatic flow may increase and the size of lymphatic ducts may be magnified under the following circumstances of hypertension and cardiac diseases, particularly mitral valve dysfunction and left ventricular aneurysm [ 3 ].…”

“…Anterior spinal surgery with or without diaphragm splitting is another relevant surgery to chyloretroperitoneum. The surgery below L1 level without diaphragm splitting is prone to injure the cisterna chyli or their tributaries [ 12 ]. Chylothorax may occur secondary to postoperative chyloretroperitoneum [ 12 , 70 ].…”

Embolization Using N-butyl Cyanoacrylate for Postoperative Lymphatic Leakage: A Case Report

“…This may have been because the NBCA mass was not sufficient to obstruct the LPA, as observed in the present case (green arrowheads in Figure 1D). In cases of LPA embolization failure, cases 12,16,17, and the present case needed ULN or ULV.…”

“…14,15 Other studies indicated that earlier radiologic interventions are preferable, particularly in severe cases with lymphatic leakage of greater than 1000 to 1500 mL/day. 16,17 Further case reports and/or clinical studies are needed in order to establish an appropriate treatment strategy; however, we are currently performing earlier radiologic interventions in an attempt to reduce hospital stays, discomfort owing to complications including hypoalbuminemia, and costs.…”

Postoperative Chylothorax Successfully Treated Using Conservative Strategies

“…Chyle production is slowed by several dietary interventions implemented as soon as the diagnosis is suspected. Some authors advocate a diet consisting of medium-chain triglycerides, which will be absorbed by the portal system, reducing the net flow through the duct (8,12,13). A more decisive approach is to cease all enteral intake while providing central hyperalimentation.…”