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Journal of Indian Association of Pediatric Surgeons
     Journal of Indian Association of Pediatric Surgeons
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CASE REPORT
Year : 2009  |  Volume : 14  |  Issue : 4  |  Page : 215-217
 

Chylous ascites after nephrectomy without lymphadenectomy for malignant rhabdoid tumor of the kidney: A rare occurrence and literature review


1 1st Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
2 Pediatric Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan

Date of Web Publication4-Feb-2010

Correspondence Address:
Takahiro Einama
1st Surgery, Hokkaido University Graduate School of Medicine, Kita-Ku, Kita 14, Nishi 7, Sapporo 060-8638
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9261.59605

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   Abstract 

Chylous ascites (CA) is an extremely rare complication of abdominal surgery in children. This report describes a 4-month-old girl with malignant rhabdoid tumor of the kidney (MRTK), who developed CA after left nephrectomy without lymphadenectomy, and who was successfully treated conservatively with enteral therapy. The literature on CA after nephrectomy without lymphadenectomy for MRTK is reviewed herein, and the clinical problems of postoperative CA are discussed.


Keywords: Chylous ascites, malignant rhabdoid tumor of the kidney, nephrectomy


How to cite this article:
Einama T, Okada T, Sasaki F, Todo S. Chylous ascites after nephrectomy without lymphadenectomy for malignant rhabdoid tumor of the kidney: A rare occurrence and literature review. J Indian Assoc Pediatr Surg 2009;14:215-7

How to cite this URL:
Einama T, Okada T, Sasaki F, Todo S. Chylous ascites after nephrectomy without lymphadenectomy for malignant rhabdoid tumor of the kidney: A rare occurrence and literature review. J Indian Assoc Pediatr Surg [serial online] 2009 [cited 2019 Apr 22];14:215-7. Available from: http://www.jiaps.com/text.asp?2009/14/4/215/59605



   Introduction Top


Chylous ascites (CA) is a rare condition mostly caused by the diseases that interfere with the abdominal or retroperitoneal lymphatic glands. Postoperative CA always represents a difficult problem in patient treatment. Patients are further debilitated by the serious mechanical, nutritional, and immunological consequences of the constant loss of protein and lymphocytes. [1]

We report a first case of CA after left nephrectomy without lymphadenectomy for stage IV malignant rhabdoid tumor of the kidney (MRTK) to our knowledge. The pathophysiology of occurrence, possible etiologic factors, and principles of management of CA after nephrectomy without lymphadenectomy for MRTK are discussed.


   Case Report Top


A 4-month-old girl was referred to our hospital for further evaluation of a large left abdominal mass and a right lung mass. Physical examination revealed a well-nourished infant, and a large solid mass was felt in the left upper quadrant of the abdomen. The mass did not cross over the midline, and its surface was smooth. Enhanced computed tomography showed neither swelling of abdominal lymph nodes nor metastases in the liver [Figure 1]. Chest radiography and computed tomography revealed metastasis to bronchopulmonary segment 5 in the right lung. These radiographic images and clinical findings suggested Wilms' tumor with lung metastasis.

The patient underwent left nephrectomy by laparotomy. The left renal artery and vein were resected with the renal hilum. Because there was no hilar and periaortic lymph node, lymph node sampling was not performed. An abdominal drainage tube was inserted into the renal bed. Histopathologic examination revealed a diagnosis of MRTK.

On postoperative day 3, we initiated oral intake, and slight abdominal distension developed. A total of 40 ml of milky fluid was aspirated from the left abdominal cavity, and was found to exhibit the chemical characteristics of chyle (triglyceride level of 632 mg/dl, and total protein 2.1 g/dl).

We then discontinued oral intake and started peripheral parenteral nutrition. On the seventh postoperative day, the chylous drainage decreased to 10 ml per day, and the triglyceride level in chyle was reduced. Limited oral feeding, consisting mainly of medium chain triglyceride (MCT) formula, was then started. She was maintained on MCT formula for 3 days. By the 10th postoperative day, the level of triglycerides in ascites returned to within the normal range (triglyceride level of 100 mg/dl, and total protein 3.3 g/dl). The patient has been maintained on an MCT formula for 1 month, and has experienced no recurrence of CA.


   Discussion Top


The development of postoperative CA has been described infrequently in the pediatric field. As in adults, the usual cause is operative injury to the thoracic duct, cisterna chyli, or their major tributaries, and another contributing factor may be obstruction of the abdominal lymphatic channels due to malignancy. [2]

Anatomically, CA results from a rent in the thoracic duct, cisterna chyli, or its intestinal tributaries. The cisterna chyli is located at the level of the renal hilum and may be disrupted during the resection of retroperitoneal lymph nodes. [3] Lymph node dissection is not needed during nephrectomy for Wilms' tumor and MRTK, but lymph node sampling or biopsy is recommended. [4] In the present case, because there was no hilar and periaortic lymph node, lymph node sampling was not performed and we undertook a simple left nephrectomy without lymphadenectomy. We identified only two previous patients with CA after nephrectomy of MRTK without lymphadenectomy. [5],[6] These and the present patient have few characteristics in common [Table 1].

The reason for these cases of postoperative CA after nephrectomy without lymphadenectomy remains unknown. In the present case, lymphatic leakage was likely to have resulted from disruption of the lymphatic tracts, for example, during mass ligation, or due to overusing an electric surgical knife. Additionally, the cisterna chyli, which is located at the level of the renal hilum, may be disrupted during resection of the renal artery and vein in the renal hilum.

If the postoperative clinical course leads to the suspicion of chylous leakage or the accumulation of CA, diagnostic and therapeutic paracentesis is usually indicated. After the diagnosis of CA is established, most patients are placed on nonsurgical therapy. Aalami et al. performed a retrospective collective review of case reports of 156 patients with CA due to various causes. [7] Of these cases, 33% were managed successfully by surgery, while 67% were resolved after conservative treatment. The mainstay of nonoperative therapy for CA is an MCT diet and total parenteral nutrition to achieve a decreased lymph flow in the major lymphatic tracts and facilitate the closure of chylous fistulas. Surgical treatment, including direct repair of leaking lymphatic glands and peritoneovenous shunt placement, should be reserved for the patients in whom conservative management has been used for at least 4 weeks. [8],[9]

In summary, we need to consider that CA can occur after nephrectomy in an infant even without lymph adenectomy as a complication.


   Acknowledgment Top


The authors thank Dr. Ryouji Kobayashi and Dr. Makoto Kaneda for pediatric assistance.

 
   References Top

1.Boyd WD, McPhail NV, Barber GC. Chylous ascites following abdominal aortic aneurysmectomy: Surgical management with a peritoneovenous shunt. J Cardiovasc Surg (Torino) 1989;30:627-9.   Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Jayabose S, Kogan S, Berezin S, Slim M, San Filippo JA, Godine L, et al. Combined occurrence of chyloperitoneum and chylothorax after surgery and chemotherapy for Wilms' tumor. Cancer 1989;64:1790-5.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.Bigley HA Jr, Chenault OW Jr. Chylous ascites following retroperitoneal lymphadenectomy. J Urol 1975;114:948-50.  Back to cited text no. 3  [PUBMED]    
4.Shamberger RC, Guthrie KA, Ritchey ML, Hasse GM, Takashima J, Beckwith JB et al. Surgery-related factors and local recurrence of Wilms tumor in National Wilms Tumor Study 4. Ann Surg 1999;229:292-7.  Back to cited text no. 4      
5.Weiser AC, Lindgren BW, Ritchey ML, Francol I. Chylous ascites following surgical treatment for Wilms tumor. J Urol 2003;170:1667-9.  Back to cited text no. 5      
6.Mladinic-Vulic D, Krzelj V, Balarin L, Saraga M, Budimir D, Vukic Z, et al. Postoperative chylous ascites. Acta Paediatr 1995;84:949-51.  Back to cited text no. 6      
7.Aalami OO, Allen DB, Organ CH Jr. Chylous ascites: A collective review. Surgery 2000;128:761-78.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]  
8.Unger SW, Chandler JG. Chylous ascites in infants and children. Surgery 1983;93:455-61.  Back to cited text no. 8  [PUBMED]    
9.Leibovitch I, Mor Y, Golomb J, Ramon J. The diagnosis and management of postoperative chylous ascites. J Urol 2002;167:449-57.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]  


    Figures

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    Tables

  [Table 1]



 

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    Abstract
    Introduction
    Case Report
    Discussion
    Acknowledgment
    References
    Article Figures
    Article Tables

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