Refractory hepatic lymphorrhea after total pancreatectomy. Case report and literature review of this uncommon complication

Michele Bartoli; Gian Luca Baiocchi; Nazario Portolani; Stefano Maria Giulini

doi:10.1016/j.ijscr.2015.09.023

Refractory hepatic lymphorrhea after total pancreatectomy. Case report and literature review of this uncommon complication

Int J Surg Case Rep. 2015:16:134-6. doi: 10.1016/j.ijscr.2015.09.023. Epub 2015 Sep 26.

Authors

Michele Bartoli¹, Gian Luca Baiocchi², Nazario Portolani², Stefano Maria Giulini²

Affiliations

¹ Department of Medical and Surgical Sciences, Surgical Clinic, University of Brescia, Brescia Civil Hospital, P.le Spedali Civili, 1, 25123 Brescia, Italy. Electronic address: michelebartoli83@gmail.com.
² Department of Medical and Surgical Sciences, Surgical Clinic, University of Brescia, Brescia Civil Hospital, P.le Spedali Civili, 1, 25123 Brescia, Italy.

Abstract

Introduction: After extended abdominal lymphoadenectomy, lymphatic vessel injury may cause lymphorrhea that usually disappears spontaneously. However, intractable ascites sometimes develops. Although there are many reports describing persistent chylous ascites from intestinal lymphorrhea, little is known about hepatic lymphorrhea, not containing chyle. It is caused by injury of the lymphatic vessels during hepatoduodenal ligament lymphadenectomy. We present a case of massive ascites due to hepatic lymphorrhea after total pancreatectomy and extended lymhoadenectomy for Ampullar adenocarcinoma. We successfully treated it with prolonged medical therapy after surgical relaparotomy.

Presentation of case: A 65-year old man underwent total pancreatectomy with extended nodal dissection. Massive clear-colored ascites (2000-9000mL per day) developed since the second postoperative day and persisted despite conservative therapy. At re-laparotomy no lymphatic leakage was found. Similarly lymphangiography was showed no contrast spreading. We treated this hepatic lymphorrea with intermittent opening of the abdominal drainage until spontaneous resolution.

Discussion: The standard treatment of hepatic lymphorrhea is an aggressive medical treatment. After such approach the most effective therapy seems to be surgical exploration. Other option are peritoneovenous shunt or intraperitoneal administration of OK-432.

Conclusion: In our experience the intermittent abdominal drainage until spontaneous resolution is an useful approach to hepatic lymphorrhea.

Keywords: Chylous ascites; Hepatoduodenal ligament; Lymphadenectomy; Lymphangiography; Refractory hepatic lymphorrhea.