van der Gaag Niels A, Verhaar Andries C, Haverkort Elizabeth B, Busch Olivier R C, van Gulik Thomas M, Gouma Dirk J
Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
J Am Coll Surg. 2008 Nov;207(5):751-7. doi: 10.1016/j.jamcollsurg.2008.07.007. Epub 2008 Aug 23.
Chylous ascites (CA) is a complication that follows thoracic and abdominal surgery, recognized after provocation by enteral feeding and characterized by its milky appearance from an elevated triglyceride level. The aim of this study was to evaluate incidence, management, and predisposing factors of CA and its impact on outcomes after pancreaticoduodenectomy.
Between 1996 and 2007, 609 consecutive patients underwent pancreaticoduodenectomy. Patients having a drain output with a milky appearance, and with a triglyceride level greater than 1.2 mmol/L, were compared with patients without significant drain production or with a low triglyceride level. Management of CA was reviewed.
Sixty-six patients had isolated CA (11%) of any measurable volume, 440 patients (72%) had no CA, and 109 patients (16%) were excluded from analysis. CA was diagnosed on postoperative day 6 (median; interquartile range 5 to 8), generally after introduction of a normal (polymeric low-chain-triglyceride) diet. Female gender (odds ratio, 1.79; 95% CI, 1.05 to 3.03) and chronic pancreatitis at pathology (odds ratio, 2.52; 95% CI, 1.19 to 5.32) were independently associated with development of isolated CA. A low-chain-triglyceride-restricted diet was initiated in 47 patients, 3 were started on total parenteral nutrition, and an expectative approach was followed in 16 patients. CA resolved after 3.5 days (median; interquartile range, 2 to 5). Isolated CA was significantly associated with prolonged hospital stay (p=0.002).
We propose a novel definition and grading system for CA after pancreaticoduodenectomy, according to which the incidence is 9%, with clinically significant CA occurring in 4% (grades B and C). Although female gender and (focal) chronic pancreatitis were associated with development of isolated CA, no predisposing factors that could readily anticipate CA were identified. Isolated CA was associated with prolonged hospital stay.
乳糜性腹水（CA）是胸腹部手术后的一种并发症，在肠内喂养激发后被识别，其特征为因甘油三酯水平升高而呈乳状外观。本研究的目的是评估CA的发生率、管理、诱发因素及其对胰十二指肠切除术后结局的影响。
1996年至2007年期间，609例连续患者接受了胰十二指肠切除术。将引流液外观呈乳状且甘油三酯水平大于1.2 mmol/L的患者与无明显引流液产生或甘油三酯水平低的患者进行比较。回顾了CA的管理情况。
66例患者出现任何可测量体积的孤立性CA（11%），440例患者（72%）无CA，109例患者（16%）被排除在分析之外。CA在术后第6天（中位数；四分位间距5至8）被诊断出来，通常是在开始正常（聚合低链甘油三酯）饮食之后。女性（比值比，1.79；95%可信区间，1.05至3.03）和病理检查发现慢性胰腺炎（比值比，2.52；95%可信区间，1.19至5.32）与孤立性CA的发生独立相关。47例患者开始采用低链甘油三酯限制饮食，3例开始接受全胃肠外营养，16例采用观察等待方法。CA在3.5天（中位数；四分位间距，2至5）后消退。孤立性CA与住院时间延长显著相关（p = 0.002）。
我们提出了一种胰十二指肠切除术后CA的新定义和分级系统，据此发生率为9%，临床上有意义的CA发生在4%（B级和C级）。虽然女性和（局灶性）慢性胰腺炎与孤立性CA的发生有关，但未发现可轻易预测CA的诱发因素。孤立性CA与住院时间延长有关。
