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Refractory congenital chylous ascites: First report of fibrin glue and mesh application by laparoscopy
Sunita Ojha1, Lalit Bharadia2, Anupam Chaturvedi2
1 Department of Neonatal and Pediatric Surgery, Santokba Durlabhji Memorial Hospital and Research Institute, Jaipur, Rajasthan, India
2 Department of Pediatrics, Santokba Durlabhji Memorial Hospital and Research Institute, Jaipur, Rajasthan, India
| Date of Submission | 07-Jul-2021 |
| Date of Acceptance | 23-Sep-2021 |
| Date of Web Publication | 10-Mar-2022 |
Correspondence Address:
Sunita Ojha,
Department of Neonatal and Pediatric Surgery, Santokba Durlabhji Memorial Hospital and Research Institute, Jaipur, Rajasthan
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/jmas.jmas_228_21
Chylous ascites (CA) is a form of ascites having leakage of lipid-rich lymph into the peritoneal cavity, due to damage or obstruction in the lymphatic system. Aetiology of CA could be congenital or acquired. Primary lymphatic hypoplasia is seen commonly in children and presents with lymphoedema, chylothorax or CA. CA is initially treated conservatively with the aim to provide gut rest and decrease intestinal secretions. Surgical treatment is recommended if 1–2 months of conservative approach fails. The success of the operation depends on identifying the site of leakage of the lymphatic duct. Surgical options are ligation of leaking lymphatics, peritoneo-venous shunt, laparotomy and fibrin glue. Laparoscopy has been used for diagnosis but not for glue and mesh application in congenital CA where the lymphatic leak is unidentified. We present here the first experience of laparoscopic fibrin glue and mesh application in congenital CA with successful outcomes.
Keywords: Congenital chylous ascites, fibrin glue, laparotomy, surgery in chylous ascites
How to cite this URL:
Ojha S, Bharadia L, Chaturvedi A. Refractory congenital chylous ascites: First report of fibrin glue and mesh application by laparoscopy. J Min Access Surg [Epub ahead of print] [cited 2022 May 28]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=339343 |
| ¤ Introduction | |  |
Chylous ascites (CA) is a form of ascites having leakage of lipid-rich lymph into the peritoneal cavity, due to damage or obstruction in the lymphatic system. Aetiology of CA could be congenital or acquired due to cirrhosis, tuberculosis, filiariasis or postsurgical. Idiopathic causes having leaky lymphatics account for 30% of cases of congenital CA. Ninety percent of cases respond to medical treatment by strict gut rest and somatostatin analogue, but refractory cases need surgical intervention. Cases of congenital CA where no definite leak is identified are difficult to treat. Case reports of using laparoscopy for exploration and diagnosis followed by laparotomy for fibrin glue/mesh application have been reported,[1],[2] but the total laparoscopic approach for glue and mesh application in congenital CA has not been reported. We present our first experience with complete laparoscopic approach for fibrin glue and mesh application with successful outcomes for refractory congenital CA.
| ¤ Case Report | | |
A 7-month-old, full-term, female child presented to us with massive abdominal distension, inguinal hernia and oozing of fluid from tense protruding umbilical hernia [Figure 1]a. At birth, she had mild distension which increased after feeding. Ascitic tap showed milky-white fluid with the presence of chylomicrons, triglycerides and cholesterol. Child was on medium-chain triglycerides (Monogen) diet since then and had undergone medical treatment with six times paracentesis, twice strict gut rest for 4 weeks with total parenteral nutrition (TPN) and octreotide infusion. Massive ascites developed on the resumption of feeds. The child presented to us at 7 months of age when laparoscopy was planned. Magnetic resonance (MR) lymphangiography could not identify the definite lymphatic leak and cisterna chyle. Six hours before surgery fat-rich milk with Sudan dye was given but no definite lymphatic leak was identified during surgery. On laparoscopy, retroperitoneum was exposed [Figure 1]b. Kocherisation of the duodenum was done to dissect at inferior vena cava (IVC), aorta and renal artery for lumbar lymphatics. Few thin lymphatics were identified around IVC and aorta, but no leak was appreciated [Figure 1]c. Lesser sac was opened to dissect at left gastric artery, splenic artery, hepatic artery and right crus of diaphragm and aorta, to apply glue and mesh at the location of cisterna chyle and celiac axis [Figure 2]a. Fibrin glue was applied and strips of vicryl mesh were put over the entire exposed retroperitoneum [Figure 2]b and [Figure 2]c. Vicryl was also fixed by sutures to retroperitoneal tissues. After surgery child was kept on gut rest and octreotide infusion at 3ug/kg/h for 2 weeks and then normal feeds were resumed. In follow-up of 3 years, the child is growing well on normal diet with no ascites on ultrasonography. | Figure 1: (a) Child with congenital chylous ascites, massive distension and tense umblical hernia. (b) Complete retroperitoneum exposed. Right kidney, inferior vena cava and aorta visualised. (c) Suction tip at inferior vena cava, fine lymphatics (white arrow), Aorta (black arrow)
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 | Figure 2: (a) Hepatic artery (arrow 1), left gastric artery/vein (arrow 2), splenic artery (arrow 3), right crus of diaphragm (arrow 4). (b) Glue instillation. (c) Mesh application to cover retroperitoneum
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| ¤ Discussion | | |
Primary lymphatic hypoplasia is seen commonly in children and presents with lymphoedema, chylothorax or CA. Primary treatment is medical management which requires to keep patient strictly nil by mouth, somatostatin/octreotide infusion and TPN for 4–6 weeks.
If CA persists for more than 10 weeks of bowel rest, surgery is the option. MR lymphangiography may help in identifying lymphatic leaks that can be ligated or macroscopic localised anomaly which can be resected.[3] In cases where no lesion or leak is identified peritoneo-venous shunt or glue/mesh application are the options. Peritoneo-venous shunt has complications like perforation and shunt block.[3] Successful outcome has been reported with glue and mesh application in cases of unidentified leaks. Laparoscopy has been used successfully for ligation of lymphatics in cases of the identifiable leak.[4] but where no leaks are identified glue and mesh application has been done by converting to laparotomy.[1],[2]
Cisterna chyle is located at the T11-L2 vertebra anteriorly, between the aorta and right crus of the diaphragm. Intestinal trunk ascends on left of descending aorta, superior to the left renal artery, crosses second lumbar vertebra anteriorly and joins left or right lumbar trunk to form common trunk, which extends to cisterna chili or thoracic duct.[5] Wide variation in formation of trunks and location of cisterna chyli is known. Sites of the expected leak are the root of mesentery, celiac trunk, right and left lumbar lymphatics and cisternal chyli. Hence, glue and mesh application in retroperitoneum is recommended in these areas in case of unidentified leaks for successful outcomes.
Retroperitoneal dissection in these areas is feasible with laparoscopic magnification and spacious distended abdomen. Thorough instillation of glue and mesh application in these recommended areas is important to achieve good seals and successful outcomes in cases with unidentified leaks.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Acknowledgments
We acknowledge the contribution of Dr Goutam Sen for manuscript correction and Jophy Jose, Arpita Chippa for technical support.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| ¤ References | | |
| 1. | Carr BD, Grant CN, Overman RE, Gadepalli SK, Geiger JD. Retroperitoneal exploration with Vicryl mesh and fibrin tissue sealant for refractory chylous ascites. J Pediatr Surg 2019;54:604-7.  |
| 2. | Saxena R, Suchiang B, Pathak M, Sinha A. Refractory congenital chylous ascites: Role of fibrin glue in its management. J Indian Assoc Pediatr Surg 2020;25:245-7. [Full text] |
| 3. | Allaghdady A, El-Asmar KM, Moussa M, Abdelhay S. Surgical management of congenital chylous ascites. Ann Pediatr Surg 2018;14:56-9. |
| 4. | Kuroiwa M, Toki F, Suzuki M, Suzuki N. Successful laparoscopic ligation of the lymphatic trunk for refractory chylous ascites. J Pediatr Surg 2007;42:E15-8. |
| 5. | Ji RM, Jiang EP, Shen XJ, Xiong SH, Lin N, Liu F, et al. The anatomic study of chyle leakage due to operation on abdominal region. Zhonghua Wai Ke Za Zhi 2004;42:857-60. |
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