Chylous Ascites after Pancreaticoduodenectomy: Introduction of a Grading System

van der Gaag, Niels A.; Verhaar, Andries C.; Haverkort, Elizabeth B.; Busch, Olivier R.C.; van Gulik, Thomas M.; Gouma, Dirk J.

doi:10.1016/j.jamcollsurg.2008.07.007

« Previous Next »Journal of the American College of Surgeons
Volume 207, Issue 5 , Pages 751-757, November 2008

Chylous Ascites after Pancreaticoduodenectomy: Introduction of a Grading System

Presented at the biannual meeting of the Dutch Society of Gastroenterology, Veldhoven, The Netherlands, October 2006 (oral presentation), and at Digestive Disease Week, Washington, DC, May 2007 (poster presentation).

Niels A. van der Gaag, MD
- Department of Surgery, Academic Medical Center at the University of Amsterdam, Amsterdam, The Netherlands
Andries C. Verhaar, MD
- Department of Surgery, Academic Medical Center at the University of Amsterdam, Amsterdam, The Netherlands
Elizabeth B. Haverkort, MSc
- Department of Dietetics, Academic Medical Center at the University of Amsterdam, Amsterdam, The Netherlands
Olivier R.C. Busch, MD
- Department of Surgery, Academic Medical Center at the University of Amsterdam, Amsterdam, The Netherlands
Thomas M. van Gulik, MD
- Department of Surgery, Academic Medical Center at the University of Amsterdam, Amsterdam, The Netherlands
Dirk J. Gouma, MD
- Department of Surgery, Academic Medical Center at the University of Amsterdam, Amsterdam, The Netherlands
- Correspondence address: DJ Gouma, MD, Department of Surgery, Academic Medical Center, Meibergdreef 91105 AZ Amsterdam, The Netherlands

Received 19 May 2008; received in revised form 30 June 2008; accepted 2 July 2008. published online 26 August 2008.

Background

Chylous ascites (CA) is a complication that follows thoracic and abdominal surgery, recognized after provocation by enteral feeding and characterized by its milky appearance from an elevated triglyceride level. The aim of this study was to evaluate incidence, management, and predisposing factors of CA and its impact on outcomes after pancreaticoduodenectomy.

Study Design

Between 1996 and 2007, 609 consecutive patients underwent pancreaticoduodenectomy. Patients having a drain output with a milky appearance, and with a triglyceride level greater than 1.2 mmol/L, were compared with patients without significant drain production or with a low triglyceride level. Management of CA was reviewed.

Results

Sixty-six patients had isolated CA (11%) of any measurable volume, 440 patients (72%) had no CA, and 109 patients (16%) were excluded from analysis. CA was diagnosed on postoperative day 6 (median; interquartile range 5 to 8), generally after introduction of a normal (polymeric low-chain-triglyceride) diet. Female gender (odds ratio, 1.79; 95% CI, 1.05 to 3.03) and chronic pancreatitis at pathology (odds ratio, 2.52; 95% CI, 1.19 to 5.32) were independently associated with development of isolated CA. A low-chain-triglyceride–restricted diet was initiated in 47 patients, 3 were started on total parenteral nutrition, and an expectative approach was followed in 16 patients. CA resolved after 3.5 days (median; interquartile range, 2 to 5). Isolated CA was significantly associated with prolonged hospital stay (p=0.002).

Conclusions

We propose a novel definition and grading system for CA after pancreaticoduodenectomy, according to which the incidence is 9%, with clinically significant CA occurring in 4% (grades B and C). Although female gender and (focal) chronic pancreatitis were associated with development of isolated CA, no predisposing factors that could readily anticipate CA were identified. Isolated CA was associated with prolonged hospital stay.

Abbreviations and Acronyms: CA, chylous ascites, IQR, interquartile range, LCT, low-chain triglyceride, OR, odds ratio, PD, pancreaticoduodenectomy, PPPD, pylorus-preserving pancreaticoduodenectomy, TG, triglyceride, TPN, total parenteral nutrition