Management of chylous lymphorrhea after retroperitoneal surgery

Lymph node dissection represents the most accurate and reliable staging procedure for lymph node invasion in urological cancers and remains the gold standard for nodal assessment.

Chylous lymhorrhoea is an infrequent complication of retroperitoneal surgery that usually develops as a result of operative trauma caused by the interruption of major lymphatic channels[1]. In a retrospective study by Press et al[2], it occurred with a frequency of 1 out of 20,664 hospital admissions. In a study by Baniel et al, its incidence was of 2 % [3]. Increased chyle production and obstruction of the abdominal lymphatic drainage may further contribute to the pathogenesis[4].

Although it remains a rare complication of  RPLND, its management becomes challenging for the urologist when the lymphorrhoea is massive and persistent.

We report a case of refractory chylous lymphorrhoea following retroperitoneal surgery for a cystic lymphangioma that did not respond to conventional conservative measures and resolved rapidly after administration of somatostatin.

A 50 year-old woman presented with left abdominal pain. An abdominal CT scan revealed a 13×9×6cm retroperitoneal mass for which she underwent laparotomy. Final pathological examination revealed a cystic lymhangioma. She was discharged, well,  on the sixth post operative day.

Three weeks after the operation, she presented complaining of abdominal pain. Evaluation with abdominal tomography (figure 1) revealed a large left retroperitoneal collection 21×10×11 cm in size. A chylous lymphorrhoea was suspected and the patient was hospitalized for conservative management.

CT guided drainage of the collection was performed and yielded 4200 ml of milky fluid. Laboratory analysis revealed a triglyceride level of 858 mg/dl, cholesterol of 69 mg/dl and an albumin level of 2 g/dl which is biochemically compatible with chyle.

Oral intake was discontinued and total parenteral nutrition (TPN) was commenced. The drainage liquid became clear within 36 hours but continued to yield between 1000 and 1500 ml per 24 hours. Ten days after hospitalization, continuous intravenous administration of  somatostatin 6mg per 24 hours was started. The drainage liquid started decreasing significantly the following day and reduced to an insignificant amount within a few days. After one week, the somatostatin dose was decreased to 3mg per day for two days then stopped, the drain was removed, parenteral nutrition was discontinued and oral intake allowed with a restricted fat content.

A CT scan was performed  once the somatostatin therapy stopped and showed a significant regression of the collection (figure 2).

The patient was discharged and returned a month later for a further CT (figure 3) which demonstrated that the collection had almost completely resolved.

Somatostatin is a naturally occurring peptide hormone, present in the central nervous system, the gastrointestinal tract and the pancreas[5]. The exact mechanisms involved in the “ drying effect “ of somatostatin on lymhorrhoea are not completely understood. Nevertheless, somatostatin was previously shown to reduce intestinal absorption of fat and attenuate lymph flow in major lymphatic channels[6]. In addition, it also reduces gastric, pancreatic and intestinal secretions and decreases splanchnic blood flow which may further contribute to the decreased lymph production[7].

The initial use of somatostatin to treat post operative lymphorrhoea was reported by  Ulibarri et al[8]. Subsequently, others also achieved satisfactory results in the treatment of lymphorrhoea using somatostatin[9,10]. Typically, the response to continuous intravenous administration of somatostatin is characterized by a drastic decrease in the output, following a couple of days’ treatment. Rapid resolution of postoperative lymphorrhoea was also reported with subcutaneous administration of octreotide[11].

In some cases chylous lymphorrhoea may take a protracted and complicated course in spite of maximal conservative measures, necessitating  invasive measures such as peritoneovenous shunt or direct surgical lymphostasis.

The treatment of postoperative chylous lymphorrhoea is primarily conservative, intending to reduce the lymph flow in the disrupted retroperitoneal lymphatics. A trial of somatostatin therapy should be included early in the course of treatment before any invasive measures are undertaken.

1. Nurettin Boran, Aylin Pelin Cil, Gokhan Tulunay, Nejat Ozgul, M. Faruk Kose. Gynecologic Oncology, Volume 93, Issue 3, June 2004, Pages 711-714

 2.O.W. Press, N.O. Press and S.D. Kaufman, Evaluation and management of chylous ascites. Ann Intern Med,  96  (1982), p. 358.

3.J. Baniel, R.S. Foster and R.G. Rowland, et al complication of primary lymph node dissection. J Urol,  152 (1994), pp. 424–427

4. Ilan Leibovitch, Yoram Mor, Jacob Golomb, Jacob Ramon. European Urology, Volume 41, Issue 2, February 2002, Pages 220-222

 5.N.J. Demos, J. Kozel and J.E. Scerbo.  Somatostatin in the treatment of chylothorax. Chest 119 (2001), pp. 964–966

6. J.M. Collard, P.F. Laterre, F. Boemer, M. Reynaert and R. Ponlot. Conservative treatment of postsurgical lymphatic leaks with Somatostatin-14. Chest 117 (2000), pp. 902–905

7. P.C. Rimensberger, B. Muller-Schenker, A. Kalangos and M. Beghetti. Treatment of a persistent postoperative chylothorax with Somatostatin. Ann. Thorac. Surg. 66 (1998), pp. 253–254.

8. .I. Ulibarri, Y. Sanz, C. Fuentes, A. Mancha, M. Aramendia and S. Sanchez. Reduction of lymphorrhagia from ruptured thoracic duct by Somatostatin (letter). Lancet 336 (1990), p. 258.

9. K. Al-Sebeih, N. Sadeghi and S. Al-Dhahri. Bilateral chylothorax following neck dissection: a new method of treatment. Ann. Otol. Rhinol. Laryngol. 110 (2001), pp. 381–384.

10. R.F. Kelly and S.J. Shumway. Conservative management of postoperative chylothorax using Somatostatin. Ann. Thorac. Surg. 69 (2000), pp. 1944–1945.

11. M. Ferrandiere, E. Hazouard, V. Guicheteau, A. Gouchet, M. Bensenouci, C. Lamotte and C. Mercier. Chylous ascites following radical nephrectomy: efficiency of octreotide as treatment of a ruptured thoracic duct. Intensive Care Med. 26 (2000), pp. 484–485

Date added to bjui.org: 02/03/2012