Pabst T S, McIntyre K E, Schilling J D, Hunter G C, Bernhard V M
Department of Surgery, University of Arizona Health Sciences Center, Tucson 85724.
Am J Surg. 1993 Aug;166(2):194-8; discussion 198-9. doi: 10.1016/s0002-9610(05)81055-4.
Chyloperitoneum is a rarely reported complication of abdominal aortic surgery. From 1981 to 1992, we treated 5 cases of chylous ascites after operations on the abdominal aorta and reviewed 22 previously published cases. There were 22 men and 5 women, with a mean age of 63.8 years (range: 27 to 93 years). Twenty cases (74.7%) occurred after abdominal aortic aneurysm resection, 5 (18.5%) after aorto-femoral bypass for occlusive disease, and 2 (6.8%) after resection of infected aortic grafts, 1 for occlusive disease and the other for infrarenal aortic aneurysm. Abdominal distention was the most common presenting symptom, occurring in 26 (96.3%) of 27 patients. The mean time from aortic operation to the development of symptoms was 18.5 days (range: 7 to 120 days). Diagnosis was confirmed by paracentesis, which yielded lipemic, sterile fluid in all patients. Therapeutic paracentesis was not successful when used alone, but, when combined with a medium-chain triglyceride (MCT) diet or total parenteral nutrition (TPN), it resulted in resolution of chyloperitoneum in 8 of 14 patients (57.2%). TPN alone or with paracenteses and/or diuretics was successful in 9 of 15 (60%) patients. Peritoneovenous shunts resolved chylous ascites in four of five patients not responding to diet and/or TPN but resulted in one death due to sepsis. Operative ligation of the injured lymphatic channel was successful in all five patients treated by laparotomy when nonoperative efforts failed. Chyloperitoneum resolved in all but two (7.7%) patients. There were five (18.5%) deaths, but only three (11.5%) were directly related to chylous ascites. Treatment with TPN resolved chyloperitoneum in all five of our own patients. We reached the following conclusions: (1) Chyloperitoneum is a rare complication of aortic surgery; (2) This disorder should be considered whenever persistent abdominal distention appears after aortic surgery; (3) The diagnosis is easily confirmed by paracentesis; and (4) Surgery to close the lymph fistula should be reserved for those patients in whom conservative therapy with MCT diets or TPN has failed.
乳糜腹是腹主动脉手术一种鲜有报道的并发症。1981年至1992年期间，我们治疗了5例腹主动脉手术后的乳糜性腹水患者，并回顾了此前发表的22例病例。其中男性22例，女性5例，平均年龄63.8岁（范围：27至93岁）。20例（74.7%）发生在腹主动脉瘤切除术后，5例（18.5%）发生在因闭塞性疾病行主-股动脉旁路移植术后，2例（6.8%）发生在感染性主动脉移植物切除术后，1例因闭塞性疾病，另1例因肾下腹主动脉瘤。腹胀是最常见的首发症状，27例患者中有26例（96.3%）出现腹胀。从主动脉手术到出现症状的平均时间为18.5天（范围：7至120天）。通过腹腔穿刺确诊，所有患者抽出的腹水均为乳糜样、无菌性液体。单纯治疗性腹腔穿刺不成功，但与中链甘油三酯（MCT）饮食或全胃肠外营养（TPN）联合使用时，14例患者中有8例（57.2%）乳糜腹得到缓解。单独使用TPN或联合腹腔穿刺和/或利尿剂，15例患者中有9例（60%）成功。腹腔静脉分流术使5例对饮食和/或TPN无反应的患者中的4例乳糜性腹水得到缓解，但导致1例因败血症死亡。当非手术治疗无效时，通过剖腹手术对所有5例患者进行受损淋巴管结扎均获成功。除2例（7.7%）患者外，其余患者乳糜腹均得到缓解。共有5例（18.5%）死亡，但只有3例（11.5%）与乳糜性腹水直接相关。我们自己的5例患者经TPN治疗后乳糜腹均得到缓解。我们得出以下结论：（1）乳糜腹是主动脉手术的一种罕见并发症；（2）主动脉手术后出现持续性腹胀时均应考虑这种疾病；（3）通过腹腔穿刺很容易确诊；（4）对于MCT饮食或TPN保守治疗失败的患者，应保留手术闭合淋巴瘘。
