Introduction: Chyle leakage or chylous ascites is a well-recognized complication following thoracic and abdominal surgery. Chylous ascites (CA) is usually recognized after provocation by enteral feeding and characterized by its milky appearance and raised triglyceride (TG) level (>1.2 mmol/L). The incidence, management, impact on outcome and possible predisposing factors of CA after pancreatoduodenectomy (PD) for a suspected periampullary malignancy is unclear and has never been described before.
OBJECTIVE: The aim of this study is to evaluate the incidence and management of CA after (PP)PD, to evaluate the impact on patient outcome and to investigate possible predisposing factors.
Methods: Data was collected from a consecutive series of 518 patients who, in the period 1996-2005, had undergone a PD for a suspected periampullary malignancy. Routinely a silicone drain was placed dorsally of the PJ anastomosis. Patients who had a significant drain output with milky appearance and a raised triglyceride (TG) level (>1.2 mmol/L), were included for analysis (group A). They were compared with patients without significant drain production or a low TG level (group B). Patients with (concomitant) anastomotic leakage were excluded for analysis. Management of patients with isolated CA was reviewed.
Results: Fifty-eight patients (11%, 58/518) had isolated CA (group A), 383 patients did not have CA (group B) and 77 patients were excluded for analysis. CA was almost always diagnosed between the 3-9 postoperative day. Introduction of a polymeric, Low Chain Triglyceride (LCT)-containing diet provoked the occurence of CA. Patients with CA were in 83% of the cases successfully treated with a Medium-Chain Triglyceride (MCT) diet. An expectative approach was followed in 17%. None of the patients required Total Parenteral Nutrition. After a median of 3 days (range 16) CA had resolved. Isolated CA was an independent variable for a prolonged hospital stay (p=0.002). No differences between groups or possible predisposing factors for CA development could be identified.
Conclusion: Isolated CA occurs in 11% of the patients after PPPD. This rather high rate might be due to the increasingly employed concept of fast track surgery, which encompasses early introduction of enteral feeding. However, CA poses a relatively mild complication, which can be adequately treated with a MCT-diet. Isolated CA is an independent variable for a prolonged hospital stay. No predisposing factors could be identified.