Post-Operative Chylous Ascites. David Kashan, PGY-4 Richmond University Medical Center 7/30/15

Transcription

1 Post-Operative Chylous Ascites David Kashan, PGY-4 Richmond University Medical Center 7/30/15

2 HPI Patient is a 76 year old female p/w one day of worsening abdominal pain, +N/V, fevers and chills

3 HPI PMHx: A-fib, HTN, HLD, hypothyroidism, Hinchey II diverticulitis, Parkinson's Home Meds: amlodipine, aspirin, cabidopa/levodopa, diltiazem, lasix, pepcid, synthroid, lisinopril, rosuvastatin PSHx: Open cholecystectomy, appendectomy, c-section x2

4 Physical Examination Vitals: T:100.5, HR:80-95, BP:150/75 AOx3, appeared in acute distress 2/2 pain Abdomen diffusely tender to palpation, distended, +rebound, +guarding

5 Labs CBC: 22.8<12.5/36.8>276 BMP:135/4.5/95/31/12/0.4/141 Lactic Acid:1.3 Hepatic Panel: 7.2/2.7/34/20/86/0.4 PT/PTT/INR: 20/28.7/2.74

6 CXR

7 CT Abdomen/Pelvis

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9 Operative Course IVF resuscitation and antibiotics in ER Exploratory laparotomy Extensive lysis of adhesions Large abscess abutting uterus: intraoperative GYN consult Sigmoidectomy with Hartmann's for perforated diverticulitis Size #10 JP left in pelvis Transferred to SICU intubated

10 POD #1-3 Extubated, not on vasopressors Function from ostomy: Diet started JP: 200 SS

11 POD #10-13 Failure to thrive, malnutrition, persistent fevers/leukocytosis Ucx: Candida Bcx: Negative CT C/A/P: no intra-abdominal collections, B/L pleural effusions Made DNR/DNI by family

12 POD # cc of milky discharge noted from JP drain - Initial gram stain/cultures negative -Gram Stain negative, Culture: E.Faecium, S. Epidermidis - JP Triglycerides: 171>487 - Serum Triglycerides: 79

13 POD #13 -Octreotide initiated -Low fat tube feeds -Medium Chain Triglycerides

14 POD #14-20 Patient had persistent hypoalbuminemia/ malnutrition JP > 1-2 liters of day, now serous/ascites, no longer milky Persistent tachycardia/hemodynamic instability, increasing oxygen respiratory failure, anasarca Withdrawal of care/abx/treatment by family: Expired on POD 20

15 PATHOLOGY Diverticulitis with necrosis and abscess

16 Questions?

17 Chylous Ascites Anatomy Epidemiology Causes Diagnosis Treatment Conclusion

18 Anatomy Bilateral lumbar trunks> Cisterna Chyli (L2)> Thoracic Duct Thoracic Duct: Lymphatic drainage of majority of the body excluding right upper extremity, neck, head; Approximately 4 Liters T.D. usually originates around T12 T.D. crosses midline T4/T5 to left Drains at confluence of IJ + L. Subclavian Vein

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20 Chyle Primarily made up of Long chain fatty acids >Chylomicrons> triglycerides 2-4 Liters produced daily 70% made of absorbed daily fats WBC s, Proteins Electrolytes: K, Na, Ph, Cl, Ca Vitamins

21 Epidemiology In 1950s: 1/187,000 Since 1980 s: 1/11,000 Age: years of age 3:1 Female to male

22 Causes Abdominal surgery Trauma Malignancy Cirrhosis Radiation Dialysis TB/Fungal Infections/Parasitic infections Congenital

23 Diagnosis Present with vague abdominal pain/distension, n/v, milky drainage from drains/wounds, anasarca, sepsis TG level > 110 mg/dl Drainage TG/Serum TG ratio >1.0 Often have negative fluid culture Diagnostic/Therapeutic Lymphangiography

24 Bipedal Lymphangiography Inject Evans blue dye between first and second web spaes Inject Lipiodol (iodine based, radio-opaque) directly into lymphatic drainage or lymph node Therapeutic in up to 70% of cases

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27 Sclerotherapy

28 Treatment options for chylous ascites after major abdominal surgery: a systematic review Maximillian Weniger M.D., et al The American Journal of Surgery, 2015 Systematic review of PubMed, Medline, and the Cochrane Library of different types of chylous ascites associated with abdominal surgeries 27 Case series 9 Case control studies

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31 Treatment Options Variations of NPO/TPN/MCT/Octreotide Lymphangiography/Sclerotherapy Surgical Ligation Peritovenous shunting, TIPS procedure Surgery reserved for >1 liter a day output, respiratory issues, failure of conservative management after 2-3 weeks, nutritional/metabolic derangements

32 Conservative Management

33 Prevention Milk Test Give 100 ml of milk intra-operatively/within 3 hours prior to surgery Patch leak with collagen patches vs direct ligation Decreased rates of chylous ascites from 7.7% to 2.9% (5/65 vs 3/104)

34 Conclusion Higher incidence due to increased incidence of aggressive surgeries/lymph node dissections Majority managed conservatively Must have high clinical suspicion given type of surgery performed Why did we get a chylous ascites????

35 Thank You