A rare complication of colorectal surgery and its management: Chylous leakage.

Chylous leakage is a rare complication after major abdominal operations and is characterized by the collection of chylous fluid in the peritoneal cavity. Postoperative chylous leakage mainly develops as a result of surgical trauma to lymphatic channels such as lacteals, tributaries or the main lymphatic duct itself and cysterna chyli. It could be either a localized chylous leakage or diffused chylous peritoneum. The surgical procedures reported to be associated with chylous leakage are mainly the ones involving retroperitoneal dissection such as testicular cancer, pancreatic resection, abdominal aortic surgery, and gastric cancer with D3 dissection. Since it is an unusual complication, the true incidence, natural history and the proper treatment algorithms remain to be defined. The delay in treatment or mismanagement may lead to dire consequences such as loss of fluid, proteins, fats, lymphocytes and subsequent cachexia. Although a few number of cases with chylous leakage after colorectal resection have been reported, neither the incidence nor the associated factors have been stated. Here we present the management of our four cases with chylous leakage after colorectal resection. Between June 2004 and April 2010, all patients who underwent colorectal resection for cancer in Vakif Gureba Training and Research Hospital were prospectively collected in a database approved by our hospital institutional board. Informed consents were obtained from all patients. A postoperative early recovery protocol was adopted from 2006, and oral feeding was started from postoperative day 1 with clear liquids. By the third day, colorectal cancer patients received normal diet with minimal fiber content. Like colorectal cancer patients, oral feeding for gastric cancer patients was started from postoperative day 1 with clear liquids. Chylous leakage was suspected postoperatively when a milky-appearing drain effluent was observed. The diagnosis of chylous leakage was confirmed by the triglyceride level of >110 mg/dl in drain fluid. All patients underwent total parenteral nutrition immediately after the diagnosis. With the cessation of fluid drainage, patients started oral feeding with a low-fat containing diet. Before hospital discharge they resumed normal oral feeding including fats. The demographic data, clinical presentation, primary diagnosis, type and extent of surgery, tumor characteristics and stage, number of harvested lymph nodes, the drain fluid characteristics, the duration of effusion, management and complications were all noted. During the specified period, 273 colorectal resections were performed in our unit. Both open and laparoscopic resections and rarely combined other-organ resections (especially gastric) were performed. Three female and one male patient with chyloperitoneum were identified. The incidence of chyloperitoneum after colorectal resections was 1.46% (4/273). Of four patients, three underwent colorectal resection for malignant causes. In one patient, the chylous leakage was noticed after colostomy takedown where the colostomy had been fashioned earlier for obstructing rectosigmoid cancer. At follow-up period (before takedown operation) CT scan did not identify any abdominal collection and no chylous fluid was present at operation. Two patients had synchronous tumors resulting in multivisceral resections and two patients had radiotherapy before the operation. The only patient without tumor was a female patient with delayed perforated appendicitis. On exploration, both appendix and cecum were found to be perforated due to massive intraabdominal inflammation and necrosis. One patient (patient no 1) underwent percutaneous catheter placement under ultrasonographic guidance for an intraabdominal collection due to premature drain removal. The drain fluid was contaminated with gramnegative bacteria and the patient treated with appropriate antibiotics. Two patients (patient no. 1–4) had wound c i r e s p . 2 0 1 5 ; 9 3 ( 2 ) : 1 1 8 – 1 3 1