Laparoscopic management of chyle leak after Nissen fundoplication.

A 41-year-old man presented with chylous ascites 6 weeks after a laparoscopic Nissen fundoplication. The chyle leak was successfully treated with laparoscopic ligation of the leaking duct at the right crus. We would now recommend early consideration of this as a treatment option for this rare complication.

INTRODUCTION

Chyle leak is a well-documented complication of oesophagectomy, usually as a result of inadvertent damage to the thoracic duct during dissection of middle third tumours in the chest.[1] Two cases of chylous ascites complicating a laparoscopic Nissen fundoplication have been reported in the literature.[23] One was successfully managed conservatively and the other failed a trial of conservative therapy and required an explorative laparotomy. We report a case of chyle leak after laparoscopic Nissen fundoplication successfully treated with laparoscopic ligation of the leaking duct at the right crus.

CASE REPORT

A 41-year-old man with a history of gastro-oesophageal reflux disease refractory to medical therapy and confirmed on pH studies underwent an elective laparoscopic Nissen fundoplication. A pneumoperitoneum was established with a Veress needle and a 4-port approach used. The crura were dissected with a harmonic scalpel and a posterior hiatal repair performed with 2 ethibond (0) sutures. There were no perioperative or postoperative complications and the patient was discharged on day 2.

Six weeks later the patient represented with a grossly distended, painful abdomen. A computed tomography scan confirmed the presence of free fluid throughout the abdomen and pelvis. An ascitic tap yielded 15 mL of milky white fluid. Following this, an ascitic drain was inserted under radiologic guidance and 3 L of chylous fluid drained immediately. Total parenteral nutrition was commenced and enteral feeding withheld for 14 days. Despite this, chyle drainage remained high at 300–400 mL per day and attempts to reintroduce a medium chain triglyceride diet were unsuccessful.

After 3 weeks of conservative management the patient was re-explored laparoscopically. He was given 250 mL of full fat cream 2 h pre-operatively in order to facilitate identification of the leaking duct. At operation an active chyle leak was easily identified at the apex of the right crus. Two metal ligaclips were applied to each side of the defect with immediate cessation of the leak [Figure 1]. A drain was left in situ.

Figure 1

Intraoperative view of application of ligaclips to leaking duct

Total parenteral nutrition was continued for a further 24 h and then weaned off as a normal diet was introduced. No further chyle appeared in the intra-abdominal drain and this was subsequently removed on day 5 post-re-laparoscopy. The patient was discharged on day 6 and remains well at 6 months follow-up.

DISCUSSION

Laparoscopic Nissen fundoplication is a safe and effective procedure for treatment of gastro-oesophageal reflux disease. There are, however, potential complications of the procedure related to dissection of the oesophageal hiatus, including pneumothorax, haemorrhage, oesophageal or gastric perforation, vagal injury, paraoesophageal herniation and gastric volvulus.[4]

Chylous ascites complicating fundoplication is extremely uncommon, probably because the cysterna chyli usually lies posterior to the field of dissection. However, the cysterna chyli varies enormously in location, origin and morphology[5] and for this reason it is possible that the lymphatics are more prone to iatrogenic injury in some individuals. Different mechanisms of lymphatic injury have been proposed in previous reports. These include diathermy injury, retro-oesophageal dissection that extends too far posteriorly, damage to the lymphatics during mobilization and retraction of the oesophagus, and thoracic duct obstruction complicating a pre-existing congenital defect.[23]

Of the 2 previous cases, 1 was successfully managed with total parenteral nutrition alone whilst the other required a laparotomy at 6 weeks.[23] To our knowledge this is the first case report of successful laparoscopic management of a chyle leak post fundoplication. Indeed laparoscopic identification and closure of the point of chyle leakage was unexpectedly straightforward, and we would now recommend early consideration of this technique for this rare complication.