EP696 - Postoperative Chylous Ascites Following Low Anterior Resection: A Case Report

Purpose/Background: Chylous ascites is an uncommon but recognized complication following low anterior resection. Reported incidence rates generally range from 1% to 6.6% after colorectal cancer surgery. Due to its high concentration of nutrients and immunoglobulins that become biologically unavailable after accumulating in the peritoneal cavity, chylous ascites can significantly impact health and quality of life, leading to increased morbidity and mortality. Currently, there are no formal consensus guidelines in medical literature addressing the management and treatment of this complication after low anterior resection. Initial management is generally conservative, with resolution rates exceeding 80% in published cohorts. On the other hand, minimally invasive lymphatic interventions or surgical exploration are reserved for refractory cases, with clinical success rates of 65-85% in patients who do not respond to conservative therapy alone.

Methods/Interventions: This is a case of a 41-year-old female with history of prior hepatectomy and metastatic sigmoid colon cancer who underwent robotic-assisted low anterior resection with retroperitoneal dissection and periaortic lymphadenectomy as part of her treatment. A combination of electrocautery and the robotic vessel sealer were utilized to ligate the lymphatics along the cephalad portion of the infrarenal aorta prior to removing the lymph nodes and sending them for evaluation. The patient's initial postoperative course was uncomplicated, and she was discharged home on postoperative day three following return of bowel function, appropriate pain control, and reassuring laboratory values. On postoperative day seven she returned to the emergency room with pain, erythema, and milky-appearing drainage from one of her laparoscopic port-site incisions. Fluid analysis revealed elevated triglyceride levels consistent with chylous ascites. This unusual complication was treated with percutaneous drainage, complete elemental nutrition via gastrostomy tube, and octreotide administration.

Results/Outcomes: After four weeks of treatment and surveillance, her drain output significantly decreased, and her triglyceride levels normalized suggesting favorable resolution of the chyle leak. Her drain was eventually discontinued, and she was restarted on a low-fat diet with eventual removal of her gastrostomy tube and no evidence of recurrence. Her case is a challenging example of a complicated chyle leak secondary to altered lymphatics from prior hepatectomy and metastatic disease. Her nutrition management was difficult but critical to prevent complications from total parenteral nutrition while achieving chyle leak resolution without need for major interventions.

Conclusion/Discussion: This case represents a relatively rare complication following low anterior resection that was successfully managed with conservative measures, as supported by the limited data available in the literature. This emphasizes the importance of adopting a stepwise approach in the treatment of chylous ascites following colon and rectal surgery, with conservative management first, followed by minimally invasive interventions and surgery as a last resort. Further research and consensus development are needed to standardize care in this setting and to establish procedure-specific, high-quality guidelines in the near future.

Chylous ascites
Chylous fluid quantification with wound manager appliance placed upon arrival to the Emergency Department.
Periaortic lymph node dissection during low anterior resection
Different views of the robotic-assisted periaortic lymph node dissection using a combination of electrocautery and vessel sealer.