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Postoperative Chyle Leak After Major Pancreatic Resections in Patients Who Receive Enteral Feed: Risk Factors and Management Options

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Abstract

Background

Chyle leak complicates 1.3–10.8 % of pancreatic resections. Universal use of parenteral nutrition following pancreatic resection may reduce the incidence of chyle leak. However, this denies the majority of patients who do not develop chyle leak the benefits of enteral nutrition (EN). The present study aimed to identify risk factors for chyle leak following pancreatic resection within a single institution where EN was used universally.

Methods

All patients who underwent pancreatic resection between January 2007 and December 2010 were identified retrospectively. The patients had been treated according to a common unit protocol of enteral feeding; those developing chyle leak were switched to a medium-chain triglyceride (MCT) regimen. Clinical progress and recovery after surgery was evaluated. Multivariate analysis was performed to identify factors associated with chyle leak.

Results

A total of 245 patients underwent major pancreatic resection (231 pancreatoduodenectomy, 14 total pancreatectomy). Chyle leak complicated 40 cases (16.3 %). After multivariate analysis, both extensive lymphadenectomy (P = 0.002) and postoperative portal/mesenteric venous thrombosis (PVT) (P = 0.009) were independently linked with a higher incidence of chyle leak. The development of chyle leak was not associated with poorer survival or prolonged duration of hospital stay. It was associated with a significantly increased duration of abdominal drainage and reduced likelihood of early hospital discharge (P = 0.026).

Conclusions

Universal use of enteral feeding is associated with a high rate of chyle leak following pancreatic resection. Patients undergoing extensive lymphadenectomy or those who develop PVT postoperatively are at increased risk. Development of chyle leak was not associated with additional morbidity or mortality following implementation of an MCT regimen. The implication is that reactive management of chyle leak with conversion to a MCT predominant diet is safe.

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References

  1. Leibovitch I, Mor Y, Golomb J et al (2002) The diagnosis and management of postoperative chylous ascites. J Urol 167:449–457

    Article  PubMed  Google Scholar 

  2. Malik HZ, Crozier J, Murray L et al (2007) Chyle leakage and early enteral feeding following pancreaticoduodenectomy: management options. Dig Surg 24:418–422

    Article  PubMed  CAS  Google Scholar 

  3. Geisler JP, Foster RS, Sutton GP (1994) Chyloperitoneum following treatment for advanced gynecologic malignancies. Obstet Gynecol 83:883–885

    PubMed  CAS  Google Scholar 

  4. Weston PM, Greenland JE, Wallace DM (1992) Chylous ascites following retroperitoneal lymph node dissection for testis cancer. Br J Urol 70:688–689

    Article  PubMed  CAS  Google Scholar 

  5. Bacelar TS, de Albuquerque AC, de Arruda PC et al (2003) Postoperative chylous ascites: a rare complication of laparoscopic Nissen fundoplication. JSLS 7:269–271

    PubMed  Google Scholar 

  6. Guillem P, Billeret V, Houcke ML et al (1999) Successful management of post esophagectomy chylothorax by etilefrine. Dis Esophagus 12:155–156

    Article  PubMed  CAS  Google Scholar 

  7. Wu CW, Hsieh MC, Lo SS et al (1996) Results of curative gastrectomy for carcinoma of the distal third of the stomach. J Am Coll Surg 183:201–207

    PubMed  CAS  Google Scholar 

  8. al-Mousawi M, Abu Nema T (1991) Chylous ascites: a rare complication of vagotomy. Eur J Surg 157:149–150

    PubMed  CAS  Google Scholar 

  9. Prabhakaran K, Vidyadhar M, Jahoorahmad P et al (2004) Chylous ascites following liver resection—case report. Pediatr Surg Int 20:719–721

    Article  PubMed  CAS  Google Scholar 

  10. DeHart MM, Lauerman WC, Conely AH et al (1994) Management of retroperitoneal leakage. Spine 19:716–718

    Article  PubMed  CAS  Google Scholar 

  11. Crespo-Leiro MG, Ayucar A, Portela F et al (1998) Chylous ascites following heart transplantation. J Cardiovasc Surg (Torino) 39:217–219

    CAS  Google Scholar 

  12. Asfar S, Lowndes R, Wall WJ (1994) Chylous ascites after liver transplantation. Transplantation 58:368–369

    PubMed  CAS  Google Scholar 

  13. Assumpcao L, Cameron JL, Wolfgang CL et al (2008) Incidence and management of chyle leaks following pancreatic resection: a high volume single-centre institutional experience. J Gastrointest Surg 12:1915–1923

    Article  PubMed  Google Scholar 

  14. van der Gaag NA, Verhaar AC, Haverkort EB et al (2008) Chylous ascites after pancreaticoduodenectomy: introduction of a grading system. J Am Coll Surg 207:751–757

    Article  PubMed  Google Scholar 

  15. Laterre PF, Dugernier T, Reynaert MS (2000) Chylous ascites: diagnosis, causes and treatment. Acta Gastroenterol Belg 6:260–263

    Google Scholar 

  16. Weimann A, Braga M, Harsanyi L (2006) ESPEN guidelines on enteral nutrition: surgery including organ transplantation. Clin Nutr 25:224–244

    Article  PubMed  CAS  Google Scholar 

  17. Phillips M, Lordan JT, Menezes N et al (2009) Feeding patients following pancreaticoduodenectomy: a UK national survey. Ann R Coll Surg Engl 91:385–388

    Article  PubMed  Google Scholar 

  18. Braga M, Gianotti L, Vignali A et al (1998) Artificial nutrition after major abdominal surgery: impact of route of administration and composition of the diet. Crit Care Med 26:24–30

    Article  PubMed  CAS  Google Scholar 

  19. Schroeder D, Gillanders L, Mahr K et al (1991) Effect of immediate postoperative enteral nutrition on body composition, muscle function and wound healing. J Parenter Enteral Nutr 15:376–383

    Article  CAS  Google Scholar 

  20. Kudsk KA (2007) Beneficial effect of enteral feeding. Gastrointest Endosc Clin N Am 17:647–662

    Article  PubMed  Google Scholar 

  21. Bozzetti F, Braga M, Gianotti L et al (2001) Postoperative enteral verses parenteral nutrition in malnourished patients with gastrointestinal cancer: a randomised multicentre trial. Lancet 358:1487–1492

    Article  PubMed  CAS  Google Scholar 

  22. Gianotti L, Braga M, Gentilini O et al (2000) Artificial nutrition after pancreaticoduodenectomy. Pancreas 21:344–351

    Article  PubMed  CAS  Google Scholar 

  23. Goonetilleke KS, Siriwardena AK (2006) Systematic review of peri-operative nutritional supplementation in patients undergoing pancreaticoduodenectomy. JOP 7:5–13

    PubMed  Google Scholar 

  24. Intensive Care Society Standards and Guidelines (2009) http://www.ics.ac.uk/professional/standards_safety_quality/standards_and_guidelines/levels_of_critical_care_for_adult_patients. Accessed 02 Jan 2012

  25. Pedrazzoli S, DiCarlo V, Dionigi R et al (1998) Standard versus extended lymphadenectomy associated with pancreatoduodenectomy in the surgical treatment of adenocarcinoma of the head of the pancreas: a multicenter, prospective, randomized study. Lymphadenectomy Study Group. Ann Surg 228:508–517

    Article  PubMed  CAS  Google Scholar 

  26. Schofield WN (1985) Predicting basal metabolic rate; new standards and review of previous work. Hum Nutr Clin Nutr 39(Suppl 1):5–41

    PubMed  Google Scholar 

  27. Tani M, Terasawa H, Kawai M et al (2006) Improvement of delayed gastric emptying in pylorus-preserving pancreaticoduodenectomy: results of a prospective, randomized, controlled trial. Ann Surg 243:316–320

    Article  PubMed  Google Scholar 

  28. Smoke A, Delegge MH (2008) Chyle leaks: consensus on management? Nutr Clin Pract 23:529–532

    Article  PubMed  Google Scholar 

  29. Lassen K, Kjoeve J, Fetveit T et al (2008) Allowing normal food at will after major upper gastrointestinal surgery does not increase morbidity: a randomised multicenter trial. Ann Surg 247:721–729

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Hepatobiliary and Pancreatic Surgical Unit, Department of Surgery, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK

    Mohammed Abu Hilal, David M. Layfield, Francesco Di Fabio, Irantzu Arregui-Fresneda, Ioanna G. Panagiotopoulou, Thomas H. Armstrong, Neil W. Pearce & Colin D. Johnson

  2. Academic Surgical Unit, Level-F University Hospital Southampton, University of Southampton, Southampton, UK

    Mohammed Abu Hilal & Colin D. Johnson

Authors
  1. Mohammed Abu Hilal
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  2. David M. Layfield
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  3. Francesco Di Fabio
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  4. Irantzu Arregui-Fresneda
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  5. Ioanna G. Panagiotopoulou
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  6. Thomas H. Armstrong
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  7. Neil W. Pearce
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  8. Colin D. Johnson
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Correspondence to Mohammed Abu Hilal.

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Hilal, M.A., Layfield, D.M., Di Fabio, F. et al. Postoperative Chyle Leak After Major Pancreatic Resections in Patients Who Receive Enteral Feed: Risk Factors and Management Options. World J Surg 37, 2918–2926 (2013). https://doi.org/10.1007/s00268-013-2171-x

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  • DOI: https://doi.org/10.1007/s00268-013-2171-x

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