A rare complication of D3 dissection for gastric carcinoma: chyloperitoneum

Sinan Yol 0 1 2 Erdal Birol Bostanci 0 1 2 Yusuf Ozogul 0 1 2 Murat Ulas 0 1 2 Musa Akoglu 0 1 2 0 Offprint requests to: S. Yol Ayvali Mah., 6. Cadde, 54. Sokak, 6 / 13, Kecioren, Ankara, Turkey Presented as an abstract at the 12th World Congress of the International Association of Surgeons and Gastroenterolo- gists , Istanbul, 2002. Received: August 12, 2004 / Accepted: November 17, 2004 1 Department of Gastrointestinal Surgery, Turkish Yuksek Ihtisas Hospital , Ankara, Turkey 2 Junichi Sakamoto Department of Epidemiological and Clinical Research Information Management, Kyoto University Graduate School of Medicine , Yoshidakonoe-cho, Sakyo-ku, Kyoto 606-8501, Japan Background. Chyloperitoneum is the accumulation of lymphatic fluid in the peritoneal cavity. Although uncommon, it has been reported after retroperitoneal lymph node dissection. But the incidence of this complication after radical gastrectomy is unknown. In the present study, we analyzed our patients who underwent D3 dissection for gastric carcinoma and developed chyloperitoneum. Methods. Between June 1999 and June 2002, a total of 134 patients with gastric cancer underwent radical lymph node dissection, performed according to the Japanese Research Society for Gastric Cancer guidelines, as the standard procedure for gastric cancer treatment. Of these patients, 34 underwent D3 lymphadenectomy, and chyloperitoneum was detected in 4 of them. Results. There were three male patients and one female patient. All patients were in stage III according to the International Union Against Cancer (UICC)-TNM classification. In three patient, chyle leakage was noticed during the surgery, and surgical ligation of the duct was performed. Abdominal distension developed in one patient 7 days after the surgery, and chylous ascites was diagnosed. This patient was successfully treated with fasting and total parenteral nutrition, within 2 weeks. Conclusion. The incidence of chyloperitoneum is not low, and may increase with more aggressive surgery. Surgeons should be aware of this complication after retroperitoneal lymph node dissection, and injured lymphatics must be controlled and ligated intraoperatively. - Chyloperitoneum is the accumulation of lymphatic fluid in the peritoneal cavity, and, if unrecognized during surgery, it may result in postoperative chylous ascites which is a rare complication of retroperitoneal surgery. It is caused by interruption of the thoracic duct, cisterna chyli, or their major tributaries [1]. Various surgical procedures, including abdominal aortic surgery, aortofemoral bypass, resection and replacement of the inferior vena cava, portacaval and mesocaval shunt procedures, lymphadenectomy for testicular and renal cancers, pelvic surgery for advanced gynecologic malignancies, and anterior spinal surgery have been reported as causes of postoperative chylous ascites [2]. However, chylous ascites is an unusual complication following treatment of gastric carcinoma. Only two cases of chylous ascites after a D2 dissection have been reported [3,4]. Surgical resection is the only curative treatment modality presently available for gastric carcinoma. Radical lymph node dissection is an important part of curative resection. In order to give patients with gastric cancer the broadest range of therapeutic options, surgeons began to perform more extensive lymph node dissection. D2 dissection, as defined by the Japanese Research Society for Gastric Cancer (JRSGC), is accepted as the standard practice for patients undergoing an operation with curative intent [5]. Those who need more aggressive surgery according to the extent of lymph node invasion may benefit from D3 dissection. To our knowledge, the incidence of chyloperitoneum after extended lymph node dissection has not been defined, however. In the present study, we have reported our experience with chyloperitoneum occuring during or after D3 gastric resection, in order to detail the incidence of this complication. Patients and methods In June 1999, we started using the Maruyama computer program [6] preoperatively to differentiate patients who need more extensive lymph node dissection from those for whom standard D2 dissection is enough. The incidence of lymph node metastases in each of the 16 lymph node stations, according to the JRSGC classification, was determined. When the predicted percentage of lymph node metastasis for any station of compartment 3 was more than 10%, then that lymph node station was dissected in addition to D2 dissection. All patients who underwent extended lymph node dissection between June 1999 and June 2002 were evaluated. During this period, 359 patients were admitted for gastric resection; 101 underwent palliative bypass procedure or only laparotomy, 124 needed palliative resection, and 134 underwent radical gastric resection with curative intent. Of these 134 patients, 34 underwent D3 dissection. These 34 patients formed the basis of the present report. Four (11.8%) of the 34 patients developed chyloperitoneum. There were three men and one woman, with a mean age of 60.5 years (range, 54 to 66 years). All patients were in stage III according to the International Union Against Cancer (UICC)-TNM classification. In three patients, chyle leakage was noticed during the surgery; the thoracic duct was found and surgical ligation was performed. One patient presented with abdominal distension occurring 7 days postoperatively. This patient underwent diagnostic paracentesis, which demonstrated the typical findings of chylous ascites: milky, sterile, odorless fluid with an alkaline pH, total protein level greater than 3.2 g/dl, and total fat content 3.3 g/dl. Total parenteral nutrition (TPN) was begun, and the patient was permitted nothing by mouth. After 10 days of TPN therapy, a reduction in the abdominal girth was noted. A diet high in protein and low in total fat was begun, and TPN was gradually tapered. The chylous ascites resolved completely without any need for intervention. Resection provides the most consistent chance of curing locoregional gastric cancer. For patients benefit, all tumor tissue should be resected, and such a resection can be achieved only by an extended lymph node dissection. The number of patients with gastric cancer who undergo radical surgery is increasing, with an expectancy for the prolonged survival of these patients with more aggressive surgery. As some centers are convinced that extended lymph node dissection will be beneficial for patients, D3 dissection is being performed at these centers [7]. It has been shown that morbidity increases after an extended lymph node dissection [7,8]. Also, unusual complications such as chyloperitoneum, may be encountered. Chyloperitoneum is the accumulation of lymphatic fluid within the peritoneal cavity. Although it is an uncommon condition, it has been reported after retroperitoneal lymph node dissection performed for testicular and renal cancers. But the incidence of thi (...truncated)