Laparoscopic Nissen fundoplication has become the mainstay of surgical treatment for gastroesophageal reflux disease whose most common complications consist of pneumothorax, pneumomediastinum, esophageal or gastric perforation, bleeding and mesenteric thrombosis.3
Chyloascites has been reported in the literature as a complication, but the incidence is very rare and usually occurs in retroperitoneal surgical procedures, such as lymphadenectomy, pancreaticoduodenectomy, distal spleen-renal shunt, and aortic surgery.7
This is probably due to the anatomy of the thoracic duct, and its relation to the esophagus and stomach dictate that this should be a rare event after such a procedure if carefully executed.
The thoracic duct is the largest lymphatic channel within the body. Except for the right head, neck, upper extremity, and chest, this channel is responsible for the remainder of lymphatic drainage. Flow starts at the cisterna chyli within the abdomen, acting as a confluence point for other smaller lymphatics coming from the lumbar, intestinal, liver, and inferior intercostal sources, located between the abdominal aorta and azygous vein. It courses posterior to the right crus of the diaphragm and along the right posterior mediastinum with a final destination proximal to the junction between the left subclavian and internal jugular veins.2,3
The true presence of a cisterna chyli was found in only 50% of individuals and in those missing this anatomic confluence are replaced by smaller lymphatic channels of the abdomen and lower extremities that form directly into the thoracic duct.8
The anatomic course of the thoracic duct in relation to the esophagus dictates that this complication should rarely occur after a laparoscopic Nissen fundoplication if carefully executed. However, there are 2 steps during the procedure that deserve extra attention. First, one needs to be careful when entering the retroperitoneum medial to the right half of the diaphragmatic crus when developing the retroesophageal window prior to passing the gastric fundus posteriorly. This step is crucial, because it opens up exposure to lymphatic channels, allowing for these conduits to be susceptible to laceration or thermal injury if the retroesophageal window is entered too posteriorly.3,7
The second step that leaves the thoracic duct susceptible to injury is when re-approximating the left and right halves of the diaphragmatic crus. Obstruction of the duct can occur during this maneuver.2
In this case, the former is most likely the culprit as the lymphogram clearly showed a lacerated lymphatic duct freely spilling into the abdomen. This could have been prevented by minimizing posterior dissection behind the esophagus in the correct plane.
When this complication occurs secondary to this procedure, management of these patients should start with nonoperative measures followed by operative for refractory conditions. Each patient deserves a first-line treatment modality of dietary changes consisting of low-fat, long-chain triglycerides versus keeping the patient NPO with parenteral nutrition. Most reported cases of chyloascites secondary to the Nissen procedure found in the literature did not require anything more than dietary changes.2,3,7
Cases of this complication secondary to other etiologies have been reported to have been managed along with medical therapy to include somatostatin and octreotide.9–11
Surgery should only be attempted if there is a correctable lesion, persistence of symptoms despite dietary manipulations, and deterioration of clinical status in patients with unknown etiologies.2,3
Despite attempts at nonoperative and operative management and the inability to localize the site of injury, our patient was ultimately treated by a unconventional method of lymphatic glue embolization with lymphography.
Lymphography has long been the gold standard for imaging the lymphatic system. However, due to the introduction and expanding use of cross-sectional imaging, very few interventional radiologists and centers continue to perform these studies let alone continue to maintain the skills to interpret them.12
This technology effectively located the leaking lymphatic channel in this patient and stopped the leakage with glue embolization. The specific glue used in this case was Cordis Tissue Glue (N-butyl-cyanoacrylate) mixed with Ethiodol contrast due to the glue's natural nonradiopaque characteristic. Internally, this substance becomes an adhesive very quickly and efficiently, polymerizing on contact with anionic substances, such as plasma, blood cells, endothelium or saline, provoking a local inflammatory response with fibrosis.13
To our knowledge, this was the first time lymphatic glue embolization was used to treat chyloascites secondary to a laparoscopic Nissen fundoplication; however, this technology has been used before.
This technique was first described by Cope et al in 1998.14
He has shown this technique in a series of 42 patients to be safe and effective allowing for a cure or partial response rate of 74% of patients with unremitting chylothoraces.15
Although mainly used to treat chylothoraces, the technique is the same as for chyle leakage in the abdomen. The thoracic duct is punctured transabdominally at the cisterna chyle under fluoroscopic guidance, and the duct is embolized proximal to the location of injury/leakage, may it be in the abdomen or in the chest. Using this same technique or modifications of it, others16
have been able to repeat his results. Most recently, a retrospective review of 109 patients was conducted to evaluate the efficacy of thoracic duct embolization combined with needle interruption with an overall success rate of 71%, leading them to speculate that this could possibly be used as first-line therapy. One group17
went further and attempted retrograde embolization of the cisterna chyli from the subclavian vein for the treatment of chylous ascites, although initial success was short lived.