Case Report and Literature Review: Intraoperative Injury to Cisterna Chyli During an Elective Pancreatic Resection Leads to Chylous Ascites and a Poor Outcome

Abstract

Background

Chylous Ascites is a rare condition. It develops as a result of iatrogenic injury to the cisterna chyli, thoracic duct, or their major tributaries. It leads to an increase in chyle release. Subsequently, obstruction of lymphatic return from abdomen. It is more prevalent after major abdominal procedures involving retro-peritoneum.

Case Presentation

A 65 years old female patient was admitted with a history of pain at epigastric and left upper abdominal quadrant via the emergency department at King Hussein Medical Centre. She was planned for elective Whipple’s procedure for cancer head of pancreas. This case report considers the impact of intraoperative injury to major lymphatic system leading to chylous ascites and death following her pancreatic resection. Retrospective evaluation of her records revealed an intraoperative iatrogenic injury to the cisterna chyli had occurred during Whipple’s Procedure. The injured lymphatic duct was discovered and repaired intraoperatively. The chyle drainage was resolved temporarily after 3 weeks of conservative management. Despite its resolution, it recurred after massive upper GI bleeding, which was managed operatively after failed endoscopic and embolization. The patient failed to recover and died as a direct result of her poor general condition due to the effects of an iatrogenic injury of Cisterna Chyli. We report this case of intraoperative injury to the cisterna chyli, subsequent development of chylous ascites, and its post-operative sequelae. This article considers, even if discovered and repaired intraoperatively, the impact of such injury on development of postoperative chylous ascites, nutritional insufficiency, poor prognosis, and subsequent death.

Conclusion

Chylous ascites is a rare complication of Whipple’s Procedure. It usually progresses due to iatrogenic operational trauma to a significant lymphatic channel. Even if such injury to cisterna chyli is discovered and managed intraoperatively, it carries a poor prognosis and subsequent death.

Keywords:

• Whipple’s Procedure
• WP
• Chylous ascites
• CA
• Pancreatico-Duodenectomy
• PD
• Cisterna chyli
• CC

Ethical Approval

Approval to conduct this study was obtained from King Hussein Medical Centre, Amman, Jordan. Administrative clearance was obtained from the office of King Hussein Medical Centre. Written informed consent was obtained by the patient for publication of this case report and accompanying identifiable features. We also obtained informed consent for reviewing the medical files of all 30 patients who had elective pancreatic resections at KHMC and to be used as part of this medical research.

Acknowledgments

We authors would like to thank Dr. Ali Ahmed Al-Zaazaai M.Sc and Professor Xioa Jian from Wenzhou University, China, who helped this study be published. The research team thanks all medical team and our patient for their co-operation.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the idea, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in conscripting, revising the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be answerable for all features of the work.

Disclosure

The authors declared that there were no conflicts of interests arising in the process of this study.

Additional information

Funding

There was no funding got for conducting this scheme.