Case Report
Chylous Ascites in the Setting of Roux-En-Y Gastric Bypass: Case Report and Review of the Literature
Nichole E. Zayan1, Timothy D. Wetzel1, Eleanor Fung1 and Boris Zevin1,2*
1Department of Surgery, Ohio State University, USA
2Department of Surgery, Queen’s University, Canada
*Corresponding author: Boris Zevin, Department of Surgery, Kingston General Hospital, Queen’s University, 76 Stuart Street, Victory 3, Kingston, ON, K7L 2V7, Canada
Published: 25 Oct, 2016
Cite this article as: Zayan NE, Wetzel TD, Fung E, Zevin B.
Chylous Ascites in the Setting of Roux-
En-Y Gastric Bypass: Case Report and
Review of the Literature. Clin Surg.
2016; 1: 1161.
Abstract
Roux-en-Y gastric bypass (RYGB) is one of the most frequently preformed bariatric and metabolic procedures worldwide. It can present with both early and late complications. We report a case of chylous ascites due to internal hernia in a patient who underwent open RYGB surgery 13 years prior. The patient presented with acute on chronic left upper quadrant abdominal pain with radiation to the left flank. CT scan of the abdomen and pelvis with oral and IV contrast demonstrated mesenteric and small bowel edema with a twist in the mesentery and poor pacification of the distal portion of the superior mesenteric vein, consistent with an internal hernia. At diagnostic laparoscopy internal hernia was reduced, mesenteric defect was closed, and cream-colored peritoneal fluid with elevated triglycerides (771 mg/dL) was identified. A diagnosis of chylous ascites due to obstruction of lymphatic channels from an internal hernia post RYGB was made. Internal hernia is a known complication of RYGB, which can infrequently present as chylous ascites. Surgical reduction of internal hernia and closure of mesenteric defects results in resolution of chylous ascites.
Introduction
Roux-en-Y gastric bypass (RYGB) accounts for 45% of bariatric and metabolic surgery worldwide
[1]. In 2016, this operation is performed using a minimally invasive approach in over 90% of cases.
RYGB is both a restrictive and malabsorptive operation. The restrictive component is attributed to
a small proximal gastric pouch and small aperture of gastrojejunostomy anastomosis between the
gastric pouch and the Roux limb. The malabsorptive component is attributed to exclusion of 75-150
cm of jejunum during formation of the Roux limb. Two enteric anastomoses are performed during
this operation including a proximal gastrojejunostomy and a distal jejunojejunostomy. Indications
for surgery in North America are based on 1991 NIH consensus criteria, which include: BMI ≥35 kg/
m2 with one or more obesity-related comorbidities (obstructive sleep apnea, diabetes, hypertension,
dyslipidemia and others) or BMI ≥40 kg/m2 without obesity related comorbidities [2]. Outcomes of
RYGB include a mean BMI decrease of 14.2 kg/m2, a mean absolute weight loss of 40 kg, resolution
or improvement of diabetes in 93 % of patients, improvement in hyperlipidemia in 97 %, resolution
or improvement in hypertension in 87 %, and resolution or improvement in obstructive sleep apnea
in 95 % of patients [3].
There are a number of early and late complications associated with a laparoscopic RYGB [4].
Early complications include bleeding (1.8%), anastomotic dehiscence (0.8%), infection (0.5%),
thermal injury with perforation (0.4%), pulmonary embolism and/or deep venous thrombosis
(0.4%) [5]. The most frequent late complications include internal hernia (16.1 %), stoma stenosis
(1.9%), incisional ventral hernia (1.0%), marginal ulcer (0-8%) and gastrogastric fistula (0.4%) [5].
Case Presentation
We report the case of a 46-year-old female with a surgical history of an open Roux-en-Y
gastric bypass, open ventral hernia repair without mesh, panniculectomy, Cesarean section, and
laparoscopic cholecystectomy. This patient presented with a 24-hour history of acute on chronic
left-sided upper abdominal pain with radiation to the left flank. Her pain was associated with
nausea and obstipation without vomiting. She previously had two similar episodes, which resolved
spontaneously. On physical examination she was a febrile with normal vital signs. She was tender
to palpation in the left upper quadrant without guarding or peritonitis. Laboratory investigation
demonstrated a normal complete blood count and chemistry, as well as lactate. Imaging with a
CT scan of the abdomen and pelvis with oral and IV contrast demonstrated mesenteric and small
bowel edema with a twist in the mesentery and poor pacification
of the distal portion of the superior mesenteric vein (Figures 1 and
2). A significant amount of free fluid was also identified (Figure
3). Radiographic findings were most compatible with a differential
diagnosis of mesenteric volvulus and/or an internal hernia. Operative
exploration was recommended for presumptive diagnosis of internal
hernia post-RYGB.
On diagnostic laparoscopy, the entire small bowel was
examined beginning at the terminal ileum proximally towards
the jejunojunostomy anastomosis. With gentle traction on the
common channel, the internal hernia was reduced and a defect at
the jejunojejunostomy mesentery was identified. The biliopancreatic
limb and retrocolic Roux limb were identified and examined. The
entire small bowel appeared healthy with no signs of ischemia or
infarction. The jejunojejunostomy mesenteric defect was closed
with a running non-absorbable suture. There was no evidence of a
mesenteric defect in transverse mesocolon or in the Petersen’s space.
There was a significant quantity of cream-colored intraperitoneal
fluid and evidence of engorged lymphatic vessels within the bowel
wall at the jejunojejunostomy. Peritoneal fluid was sent for culture
and sensitivity, as well as for triglyceride analysis. There were no other
abnormalities identified on diagnostic laparoscopy.
Analysis of peritoneal fluid demonstrated elevated triglycerides
at 771 mg/dl supporting the diagnosis of chylous ascites. There were
no organisms or growth on microbiology. The patient was discharged
from the hospital on 2nd post-operative day without complications.
Repeat CT scan of the abdomen and pelvis with oral and intravenous
contrast 1 month after the operation demonstrated absence of
mesenteric twist and minimal free fluid in the peritoneum.
Figure 1
Figure 2
Figure 3
Figure 4
Discussion
Internal hernia is a known late complication of RYGB. Creation
of mesenteric defects, decreased rate of adhesion formation with the
use carbon dioxide gas during laparoscopy, and postoperative weight
loss all contribute to internal hernia formation after laparoscopic
RYGB [6]. Clinicians and surgeons should be familiar with causes,
presentations, and possible complications of internal hernia following
RYGB. There are three potential spaces for an internal hernia
formation post RYGB – the jejunojejunostomy mesenteric defect,
the Petersen’s space (the space created between the mesentery of the
Roux limb and the transverse colon mesentery) and the transverse
mesocolon defect, which is seen exclusively with the retrocolic
position of the Roux limb [6] (Figure 4).
Typical presentation of an internal hernia can be either acute or
chronic with progressive or intermittent abdominal pain, epigastric
abdominal pain, and postprandial abdominal pain. Importantly,
vomiting is not a common symptom for an acute presentation of
an internal hernia [8]. Acute presentation necessitates emergent
operative exploration. Laparoscopic or open exploration is the most
sensitive test for diagnoses and treatment of an internal hernia;
however, a CT scan of the abdomen can be positive in 85% of
internal hernia cases. As such, CT scan is often used as a less invasive
modality to confirm presence of an internal hernia prior to operative
exploration [8].
Patients with chronic presentation of an internal hernia typically
describe vague, colicky abdominal pain that may change in character
or disappear when the patient is placed in the lateral decubitus
position. Nausea and postprandial vomiting may also be present
[6]. Surgical exploration is indicated if clinical suspicion of internal
hernia exists despite normal laboratory and imaging findings [7].
Closure of mesenteric defects at the time of primary RYGB
operation has been shown to significantly reduce the need for
reoperation due to an internal hernia and small bowel obstruction
in the first 3 postoperative years (1.2% vs. 5.6%, p < 0.001) [8].
Cumulative incidence of an internal hernia can also be significantly
reduced with mesenteric defect closure from 8.9 % to 2.5 % (p<
0.0001) [8].
Chylous ascites as was seen in our patient is a rare clinical
manifestation of an internal hernia post RYGB. Classic definition
of chylous ascites is triglycerides content of greater than 110 mg/
dL [9]. Chylous ascites often has the appearance of milky nonpurulent
intraperitoneal fluid. There are several etiologies of chylous
ascites. In North America, the most common etiologies are cirrhosis
and peritoneal malignancies. The pathophysiologic mechanism
responsible for the development of chylous ascites in these patients is
an obstruction of the lymphatic vessels at the root of the mesentery or
at the cisterna chyli, which results in exudation of chyle from dilated
lymphatics both on the bowel wall and in the mesentery. Another
etiology of chylous ascites is from exudation of chyle through the
walls of dilated retroperitoneal lymphatic vessels, as in the case of
lymphangiectasia or thoracic duct obstruction [9]. Direct operative
trauma is another recognized etiology, where injury to the main chyle
ducts, its branches, or lymph nodes during abdominal surgery results
in a lymph-peritoneal fistula [10]. The incidence of post-operative
chylous ascites during abdominal surgery is reported in Table 1 [10].
Surgical intervention for postoperative chylous ascites is generally
reserved for cases that are refractory to medical management, which
consists of a high protein, low fat diet that is high in medium chain
triglycerides [11]. This diet results in decreased chyli production and
flow, which successfully reduces the volume of chylous ascites in
greater than 60% of patients [12]. Refractory cases of chylous ascites
require surgical intervention, which involves identification and
ligation of the chyle leak or peritoneovenous shunting.
Chylous ascites following RYGB is uncommon. In the literature,
there are two previous reports of chylous ascites post laparoscopic
RYGB and one report following laparoscopic adjustable gastric
banding [12-14]. In the latter report, laparoscopic removal of the
gastric band, ligation of the lymphatics, and the application of
fibrin glue successfully treated patients who failed non-operative
management. In our patient, the cause of the chylous ascites
was obstruction of lymphatic vessels at the jejunojejunostomy
secondary to an internal hernia through the mesenteric defect at the
jejunojejunostomy [15]. Relief of lymphatic obstruction by reduction
of the internal hernia and closure of mesenteric defects resulted in
resolution of chylous ascites.
Conclusion
Chylous ascites is a rare complication of RYGB surgery in the setting of an internal hernia. Clinicians and surgeons should be aware of this presentation of an internal hernia and its successful management by reduction of the hernia and closure of mesenteric defects.
References
- Angrisani L, Santonicola A, Iovino P, Formisano G, Buchwald H, Scopinaro N. Bariatric surgery worldwide 2013. Obes Surg. 2015; 25: 1822-1832.
- Bariatric surgery for severe obesity. National Institute of Diabetes and Digestive and Kidney Diseases. 2011.
- Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004; 292: 1724-1737.
- Rausa E, Bonavina L, Asti E, Gaeta M, Ricci C. Rate of death and complications in laparoscopic and open Roux-en-Y gastric bypass. A meta-analysis and meta-regression analysis on 69,494 patients. Obes Surg. 2016; 26: 1-8.
- Hamdan K, Somers S, Chand M. Management of late postoperative complications of bariatric surgery. Br J Surg. 2011; 98: 1345-1355.
- Facchinao E, Leuratti L, Veltri M, Quartararo G, Iannelli A, Lucchese M. Laparoscopic Management of Internal Hernia after Roux-en-Y gastric bypass. Obes Surg. 2016; 26: 1363-1365.
- Kim Y, Crookes PF. Complications of bariatric surgery. In: Huang CK, editor. Essentials and controversies in bariatric surgery. In Tech. 2014.
- Stenberg E, Szabo E, Agren G, Ottosson J, Marsk R, Lonroth H, et al. Closure of mesenteric defects in laparoscopic gastric bypass: a multicentre, randomised, parallel, open-label trial. The Lancet. 2016; 387: 1297-1404.
- Krizek TJ, Davis JH. Acute Chylous Peritonitis: Arch Surg.1964; 91: 253- 262.
- Weniger M, D'haese JG, Angele MK, Kleespies A, Werner J, Hartwig W. Treatment Options for Chylous Ascites after Major Abdominal Surgery: A Systematic Review. Am J Surg. 2016; 211: 206-213.
- Tulunay G, Ureyen I, Turan T, Karalok A, Kavak D, Ozgul N, et al. Chylous Ascites: Analysis of 24 Patients. Gynecol Oncol. 2012; 127: 191-197.
- Hidalgo JE, Ramirez A, Patel S, Acholonu E, Eckstein J, Abu-Jaish W, et al. Chyloperitoneum after laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2010; 20: 257-260.
- Hanson M, Chao J, Lim RB. Chylous ascites mimicking peritonitis after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Surg Obes Relat Dis. 2012; 8: e1-2.
- Nau P, Narula V, Needleman B. Successful management of chyloperitoneum after laparoscopic adjustable gastric banding in 2 patients. Surg Obes Relat Dis. 2011; 7: 122-123.
- Harino Y, Kamo H, Yoshioka Y, Yamaguchi T, Sumise Y, Okitsu N, et al. Case report of chylous ascites with strangulated ileus and review of the literature. Clin Journ of Gastroenterology. 2015; 8: 186-192.