Case Report and Literature Review: Intraoperative Injury to Cisterna Chyli During an Elective Pancreatic Resection Leads to Chylous Ascites and a Poor Outcome

Abstract

Waheeb Radman Al-Kubati,1 Hanan Rihani,2 Abdelaziz Zeadat2 1Surgery Department, 21st September University, Sana’a, Yemen; 2General Surgery, King Hussein Medical Centre, Amman, JordanCorrespondence: Ass. Prof. Waheeb Radman Al-Kubati, MBBS JBS ABS IMRCSI ASCRS ACPGBI ISID ISUCRS. Surgery Department, 21st September University, Sana’a, Yemen, Tel [phone], Email [email protected]: Chylous Ascites is a rare condition. It develops as a result of iatrogenic injury to the cisterna chyli, thoracic duct, or their major tributaries. It leads to an increase in chyle release. Subsequently, obstruction of lymphatic return from abdomen. It is more prevalent after major abdominal procedures involving retro-peritoneum.Case Presentation: A 65 years old female patient was admitted with a history of pain at epigastric and left upper abdominal quadrant via the emergency department at King Hussein Medical Centre. She was planned for elective Whipple’s procedure for cancer head of pancreas. This case report considers the impact of intraoperative injury to major lymphatic system leading to chylous ascites and death following her pancreatic resection. Retrospective evaluation of her records revealed an intraoperative iatrogenic injury to the cisterna chyli had occurred during Whipple’s Procedure. The injured lymphatic duct was discovered and repaired intraoperatively. The chyle drainage was resolved temporarily after 3 weeks of conservative management. Despite its resolution, it recurred after massive upper GI bleeding, which was managed operatively after failed endoscopic and embolization. The patient failed to recover and died as a direct result of her poor general condition due to the effects of an iatrogenic injury of Cisterna Chyli. We report this case of intraoperative injury to the cisterna chyli, subsequent development of chylous ascites, and its post-operative sequelae. This article considers, even if discovered and repaired intraoperatively, the impact of such injury on development of postoperative chylous ascites, nutritional insufficiency, poor prognosis, and subsequent death.Conclusion: Chylous ascites is a rare complication of Whipple’s Procedure. It usually progresses due to iatrogenic operational trauma to a significant lymphatic channel. Even if such injury to cisterna chyli is discovered and managed intraoperatively, it carries a poor prognosis and subsequent death.Keywords: Whipple’s Procedure, WP, Chylous ascites, CA, Pancreatico-Duodenectomy, PD, Cisterna chyli, CC

Keywords

• background: chylous ascites is a rare condition. it develops as a result of iatrogenic injury to the cisterna chyli
• thoracic duct
• or their major tributaries. it leads to increase chyle release. subsequently obstruction of lymphatic return from abdomen. it is more prevalent after major abdominal procedures involving retro-peritoneum. case presentation: a 65 years old female patient was admitted with history of pain at epigastric and left upper abdominal quadrant via the emergency department at king hussein medical centre. she was planned for elective whipple’s procedure for cancer head of pancreas. this case report considers the impact of intraoperative injury to major lymphatic system leading to chylous ascites and death following her pancreatic resection. retrospective evaluation of her records
• revealed an intraoperative iatrogenic injury to the cisterna chyli had occurred during whipple’s procedure. the injured lymphatic duct was discovered and repaired intraoperatively. the chyle drainage was resolved temporarily after three weeks of conservative management. despite its resolution
• it recurred after massive upper gi bleeding which managed operatively after failed endoscopic and embolization. the patient failed to recover and died as a direct result of her poor general condition due to the effects of an iatrogenic injury of cisterna chyli. we report this case of intraoperative injury to the cisterna chyli
• subsequent development of chylous ascites
• and its post-operative sequelae. this article considers
• even if discovered and repaired intraoperatively
• the impact of such injury on development of postoperative chylous ascites
• nutritional insufficiency
• poor prognosis and subsequent death. conclusion: chylous ascites is a rare complication of whipple’s procedure. usually progresses due to iatrogenic operational trauma to the significant lymphatic channel. even if such injury to cisterna chyli is discovered and managed intraoperatively
• it carries a poor prognosis and subsequent death.