Preventing chylous ascites after right hemicolectomy with D3 extended mesenterectomy

Abstract

Background: We aim to find the incidence of chylous ascites in patients undergoing D3 extended mesenterectomy and evaluate if a routine fat-reduced diet (FRD) has a prophylactic effect.

Methods: Data from 138 patients included in a D3 extended mesenterectomy trial were collected prospectively. Surgical drains and biochemical testing of drain fluid were used to find the incidence of chylous ascites among the first 39 patients, and a prophylactic fat-reduced diet was then implemented in the next 99 patients as a prophylactic measure.

Results: In the first 39 patients, we found that 16 (41.0%) developed chylous ascites. After the fat-reduced diet was implemented, 1 (1.0%) of 99 patients developed chylous ascites. Drain discharge was 150 vs. 80 mL daily, respectively, and a regression analysis shows the average leakage in the group with fat-reduced diet was 105 mL/day less than in the patients with no dietary restrictions (p < 0.001). There were no significant differences in the rate of other complications (Fisher exact test, one-tailed p = 0.8845), and although there was a tendency to a shorter hospital stay when given a fat-reduced diet (7.3 ± 5.4 vs. 8.9 ± 4.9 days), the difference was not significant (p = 0.19).

Conclusions: Chylous ascites is a very common postoperative occurrence after right colectomy with extended D3 mesenterectomy and may be prevented using a routine fat-reduced diet.

Keywords: Chylous ascites; D3 extended mesenterectomy; Fat-free diet; Fat-reduced diet; Lymphatic leak.

Fig. 1

Left to right, operative image of the thoroughly dissected D3 area, schema of the operative image, and preoperative 3DVR of the same patient. a, tied right branch of the middle colic artery; b, tied middle colic vein; c, tied right colic artery; d, tied ileocolic artery; e, tied ileocolic vein; f, resected vascular sheath of the superior mesenteric artery; g, cut thickness of the mesenteric anterior leaf overlying the D3 area

Fig. 2

When comparing group 2 (no dietary restriction, green line) with group 3 (FRD, red line) on a group level, there is a significant difference in the amount of drain fluid (y-axis). Standard deviation (SD) illustrated as gray areas

Fig. 3

Even when we remove the patients with chylous ascites (green dotted line) from group 2 (no dietary restrictions, remaining patients in group 2 illustrated with whole green line), we see a clear difference in the amount of drain fluid (y-axis) compared with group 3 (whole red line, fat-free diet)

Fig. 4

The plot shows how many days after surgery (x-axis) the drain is kept in group 2 (no dietary restriction, green line) compared with group 3 (FRD, red line). Proportion of group with abdominal drain along the y-axis