Chylous ascites (CA) is the accumulation of chylous lymphatic fluid within the abdominal cavity, usually resulting from laceration of the cisterna chyli or one of its major tributaries during retroperitoneal surgery. If left untreated, CA may become life-threatening. Current treatment recommendations favor a stepwise approach, beginning with conservative measures, followed by percutaneous interventions and, in refractory cases, surgical shunting procedures. Conservative management typically consists of dietary restriction of long-chain triglycerides, escalation to total parenteral nutrition (TPN), and adjunctive pharmacotherapy with somatostatin analogues. In most reported cases, these measures result in cessation of chylous leakage within several days. We report a case of CA after robotic-assisted retroperitoneal lymph node dissection (RPLND) in a 35-year-old male with testicular seminoma. Conservative management included paracentesis with drain insertion, TPN, and pharmacotherapy with octreotide. Ascitic fluid analysis confirmed CA with a triglyceride level of 420 mg/dL. Because chylous leakage did not cease after 60 days of hospital-based management, home-based TPN via a central venous port was initiated. Chylous leakage finally resolved after 80 days of conservative treatment. One year later, the patient remained well and had experienced no recurrence of either CA or seminoma. This case demonstrates that conservative treatment of CA may occasionally require a prolonged course and considerable patience from both the patient and the treating team.
Angerer et al. (Mon,) studied this question.