Sakamoto Shinya, Takata Nobuo, Noda Yoshihiro, Ozaki Kazuhide, Okabayashi Takehiro
Department of Gastroenterological Surgery, Kochi Health Science Center, 2125-1 Ike, Kochi, 781-8555, Japan.
Department of Radiology, Kochi Health Science Center, 2125-1 Ike, Kochi, 781-8555, Japan.
Surg Case Rep. 2022 May 10;8(1):92. doi: 10.1186/s40792-022-01447-0.
Chylous ascites (CA) is a rare complication of gastrectomy for gastric cancer. While most cases of postoperative CA improve with medication or nutritional support, some are refractory to conservative treatment. A peritoneovenous shunt (PVS) may help patients who are poor candidates for surgery. However, PVS placement for postoperative CA after gastroenterological surgery has been rarely reported. Herein, we present a case of postoperative CA following total gastrectomy with para-aortic lymphadenectomy, treated successfully by PVS placement.
A 74-year-old man who underwent total gastrectomy with para-aortic lymph node dissection was hospitalised because of insufficient oral intake and dehydration. His abdomen was markedly distended with severe bilateral lower extremity oedema. On admission, abdominal computed tomography (CT) showed a high volume of ascites and no signs of cancer recurrence. Accordingly, postoperative CA resulting from drainage of fluid on paracentesis was diagnosed. Despite nutritional support, diuretics, and octreotide administration, his abdominal distension and nutritional status did not improve. We could not identify the sites of lymphatic leakage in the three intranodal lymphangiographies followed by CT. Although we considered a surgical treatment in our patient, we decided against it. Because we could not identify lymphatic leakage site during lymphangiography, surgical treatment might have a potential failure of detection and closure of leakage site. Furthermore, the patient's general condition was poor because of malnutrition resulting from the loss of lymphatic fluid. Consequently, we decided to place PVS. After PVS placement, his abdominal distension improved rapidly, and he was discharged without serious complications. Thirteen months after PVS, patient has no relapse of abdominal distention and nutrition status has improved.
PVS might be a good option to manage refractory postoperative CA, as the leakage point cannot be detected on lymphangiography.
乳糜性腹水（CA）是胃癌胃切除术后一种罕见的并发症。虽然大多数术后CA病例通过药物治疗或营养支持可得到改善，但有些病例对保守治疗无效。腹腔静脉分流术（PVS）可能对手术条件较差的患者有帮助。然而，胃肠外科手术后因术后CA而行PVS置入术的报道很少。在此，我们报告一例全胃切除联合主动脉旁淋巴结清扫术后发生CA的病例，通过PVS置入术成功治疗。
一名74岁男性，接受了全胃切除及主动脉旁淋巴结清扫术，因口服摄入量不足和脱水入院。他的腹部明显膨隆，双侧下肢严重水肿。入院时，腹部计算机断层扫描（CT）显示大量腹水，无癌症复发迹象。因此，经诊断为穿刺引流液导致的术后CA。尽管给予了营养支持、利尿剂和奥曲肽治疗，他的腹胀和营养状况仍未改善。在随后的三次CT引导下的淋巴结内淋巴管造影中，我们未能确定淋巴漏的部位。虽然我们考虑过对患者进行手术治疗，但还是决定放弃。因为在淋巴管造影过程中我们无法确定淋巴漏的部位，手术治疗可能存在漏诊和漏口闭合失败的风险。此外，由于淋巴液丢失导致营养不良，患者的一般状况较差。因此，我们决定置入PVS。置入PVS后，他的腹胀迅速改善，且未发生严重并发症而出院。PVS置入13个月后，患者腹胀未复发，营养状况有所改善。
对于淋巴管造影无法检测到漏点的难治性术后CA，PVS可能是一种较好的治疗选择。
