Complementary Therapies in Medicine (2015) 23, 63—67
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevierhealth.com/journals/ctim
CASE REPORT
Chylous ascites treated by traditional Chinese herbal medicine: A case report and discussion Lijuan Xiu 1, Bing Yan 1, Zhifeng Qin, Xuan Liu, Feng Wu, Xiaowei Wang, Pinkang Wei ∗ Department of Traditional Chinese Medicine, Chang Zheng Hospital, the Second Military Medical University, Shanghai 200003, China Available online 14 October 2014
KEYWORDS Chylous ascites; Postoperative complications; Traditional Chinese herbal medicine
Summary Chylous ascites, which can lead to peritonitis, intestinal obstruction, metabolic disorder, and even death from pyemia, is a rare complication of abdominal surgery. Currently, first-line treatment involves conservative management, which includes oral diet and total parenteral nutrition (TPN). However, the efficacy of these treatments cannot be guaranteed. For example, single diet control can result in consecutive drainage for up to 1 month, and salvage surgery is required for some invalid cases. Here, we report 6 cases of chylous ascites after abdominal surgery. In addition to diet control, we delivered traditional Chinese herbal medicine (TCHM) twice daily orally. The drainage volume of the chylous fistula showed an obvious decrease 1 day after the TCHM administration and all 6 patients completely recovered within 4 to 8 days (median: 5.5 days). Although relevant data are limited, our cases would suggest that TCHM could play an important role in the management of chylous ascites. However, randomized controlled trials are still needed to confirm its efficacy in a larger population. © 2014 Elsevier Ltd. All rights reserved.
Introduction It is well established that chylous ascites is a rare complication of various abdominal surgeries, with an incidence at
∗ Corresponding author at: Head of Department of Traditional Chinese Medicine Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai 200003, China. Tel.: +86 2181885476; fax: +86 2163520020. E-mail address: [email protected] (P. Wei). 1 These authors contributed equally to this work.
http://dx.doi.org/10.1016/j.ctim.2014.10.006 0965-2299/© 2014 Elsevier Ltd. All rights reserved.
about 5—11%.1—3 It can result in poor prognosis for these patients due to complications such as peritonitis, intestinal obstruction, metabolic disorder, prolonged hospital stay, and even death from pyemia.3—6 The underlying mechanism of the disease is conventionally attributed to the extensive loss of lymph nodes after resection which can lead to inadequate drainage, congested upstream lymph ducts,7 especially for those who experience operative trauma to cisterna chyli or retroperitoneal lymphatic vessels after retroperitoneal surgery.7—9 Aggressive lymphadenectomy in the para-aortic region was also regarded as a risk factor for chylous ascites.10 The main treatment approach for chylous
64 Table 1
L. Xiu et al. Ingredients and the corresponding percent of TCHM.
Chinese name
Common name
Latin name
Percent (%)
Huang Qi Yi Yi Ren Qian Shi Yu Mi Xu Yi Mu Cao Fang Feng Ma Bian Cao Jin Ying Zi Zhe Bei Mu Gan Cao
Milkvetch Root Semen Coicis Gorgon Euryale Seed Corn silk Herba Leonuri Radix Saposhnikoviae Herba Verbenae Offcinalis Fructus Rosae Laevigatae Fritillaria thunbergii Glycyrrhiza
Astragali Radix Coicis semen Semen Euryales Corn Stigma Stigma Maydis Leonurus heterophyllus Sweet Saposhnikonia divaricata (Turcz.) Schischk Verbenae Offcinalis L. Rosa Laevigata Michx Fritillariae Thunbergii Mig Radix Glycyrrhizae praeparatae
25 12.5 12.5 12.5 12.5 6.25 6.25 6.25 4.17 2.08
ascites is conservative management, aimed at reducing the lymph leak of injury retroperitoneal lymphatic.9 However, the efficacy of these treatments cannot be guaranteed. In recent years, traditional Chinese herbal medicine (TCHM) has increasingly proved to be effective in management of the postoperative complications, such as postoperative urinary retention and gastrointestinal dysfunction.12,13 However, there is no data on its role on chylous ascites. Here, we report our experience with 6 patients who underwent abdominal surgery and presented with postoperative chylous ascites. In addition to diet control, we administered TCHM after the confirmation of chylous ascites. The composition and proportions of the herbs are described in Table 1. The drainage volume of the chylous fistula showed a marked decrease 1 day after the administration of TCHM and all 6 patients completely recovered in 4 to 8 days (median: 5.5 days).
Case presentation Six patients with postoperative chylous ascites were refereed to Shanghai Changzheng Hospital, Shanghai, China from October 2011 to December 2012 (Table 2). Table 2
Case 1 A 59-year-old man presented with an obscure adrenal gland lesion and underwent a right laparoscopic adrenalectomy in 2011. After surgery, the volume of drainage was approximately 160 ml per 24 h. On the postoperative day (POD) 7, chylous ascites occurred, the patient’s tongue being pale with thin and greasy coating, and pulse being smooth. The patient was then treated with albumin, a low-fat diet and TCHM. The drainage volume immediately decreased to 87 ml/24 h, and was further reduced to 15 ml/24 h 2 days later. After that, the drains were removed and no other complications occurred.
Case2 A 68-year-old woman was diagnosed with renal cancer and underwent a left laparoscopic radical nephrectomy in 2011. The volume of drainage decreased gradually after the surgery, but increased to approximately 140 ml/24 h on POD 5 with no obvious cause. A chyle test was positive and chylous ascites was confirmed. She presented a pale tongue with thin and greasy coating, and rapid pulse. The patient was
Clinical profile of patients in whom chylous fistula developed.
Patient no.
Age
Gender
Primary site
Surgery
Biochemically proved
1
59
Male
Right laparoscopic adrenalectomy
No
2
68
Female
Right adrenal gland occupying lesion Left renal cancer
Yes
3
49
Female
Right renal cancer
4
47
Male
5
63
Male
Left non-functioning kidney Left ureteral cancer
6
57
Male
Left laparoscopic radical nephrectomy Right partial nephrectomy Left laparoscopic radical nephrectomy Left laparoscopic nephroureterectomy Cystectomy
Bladder cancer recurrence
Yes Yes
No
No
Chylous ascites treated by traditional Chinese herbal medicine Table 3
65
Management of chyle leak.
Patient no.
Type of management
Onset of chylous ascites
Average drain output (ml)
Termination of chyle leak (POD)
1 2 3 4 5 6
Low-fat Low-fat Low-fat Low-fat Low-fat Low-fat
Day Day Day Day Day Day
61 109 123 96 127 300
4 7 8 8 4 4
diet + albumin + TCM diet + TCM diet + albumin + TCM diet + TCM diet + TCM diet + albumin + TCM
5 5 7 4 5 3
simultaneously administrated a low-fat diet and TCHM. Her volume of drainage decreased to 45 ml/24 h 2 days later, and at this point the patient recovered and no other complications were reported.
greasy coating, and soft-superficial and smooth pulse. The patient received a low-fat diet, albumin and TCHM. The volume of fluid in drainage was then decreased to 50 ml/24 h 2 days later, and no other complications presented during the follow-up.
Case 3 A 49-year-old woman was diagnosed with renal cancer and underwent a right partial nephrectomy in 2011. Similar to Case 2, she presented chylous ascites on POD 5 (approximately180 ml/24 h), with no obvious cause. She presented a pale tongue with thin and greasy coating, and thread pulse. The patient was simultaneously administrated a low-fat diet, albumin and TCHM. The volume of drainage decreased to 40 ml/24 h 6 days later, and no other complications were detected in the follow-up.
Case 4 A 47-year-old man was diagnosed with a non-functioning kidney and underwent left laparoscopic radical nephrectomy in 2011. The discharge (approximately 155 ml/24 h) turned milky on POD 4 and the chyle test was positive. He presented a pale and swollen tongue with thin, white and greasy coating, and smooth pulse. The patient received a low-fat diet and TCHM. The volume of fluid in drainage was decreased to 30 ml/24 h 6 days later, and no other complications were recorded.
Case 5 A 63-year-old man was diagnosed with ureteral cancer and underwent left laparoscopic nephroureterectomy in 2012. The discharge of 260 ml/24 h turned milky on POD 5 and chylous ascites was confirmed. He presented a pale and swollen tongue with thick, white and greasy coating, and soft-superficial pulse. The patient immediately received a low-fat diet and TCHM. The volume of fluid in drainage was then decreased to 50 ml/24 h 6 days later, and no other complications were detected in the follow-up.
Case 6 A 57-year-old man presented with cystectomy due to a recurrence of bladder cancer in 2012. The discharge increased on POD 3 (approximately 340 ml/24 h). He presented a pale and swollen tongue with thick, white and
Syndrome differentiation According to the principle of traditional Chinese medicine (TCM), the Qi deficiency could be occurred in some wound situation (including surgery) since the majority of the patients would lost this important element in these processes. Taking into consideration of the role of Qi deficiency in TCM, it would be predictable that it could lead to some symptoms like fluid retention as well as delay the time of healing when it was happened. The patients’ pale or/and swollen tongue with thin or thick greasy coating combined with smooth or soft-superficial pulse accorded with Qi deficiency and dampness syndrome. Indeed, the therapeutic principle of TCM is strengthening Qi and removing dampness. In all 6 cases, chylous leakage was confirmed by the detection of milky fluid in drainage tubes or a drainage volume that was more than 200 ml/day,10 and/or drainage that proved biochemically positive. Once chylous ascites was confirmed, all the patients were treated by conservative management and TCHM 1—2 days later (Table 3), 150 ml per time at a frequency twice a day orally. The treatments were administrated until the drains were discharged. All the herbs were purchased from Cai Tongde Pharmacy Co. Ltd (Shanghai, China) and therefore had a definite origin and were of good quality. For all the patients, the drains were removed when the discharge decreased to 50 ml/24 h. As shown in Fig. 1, the average chylous leakage increased dramatically when single conservative management was adopted, but then markedly decreased once the TCHM treatment was initiated. After 4—8 days’ (median: 5.5 days) treatment, all the patients recovered and no other complications were detected in the follow-up.
Discussion In current study, we presented 6 cases of chylous ascites that were mainly treated with a single treatment as part of a conservative management approach and TCHM. We observed a marked decrease in drainage volume and a short recovery time (4—8 days) compared to previously reports. Although related data are still rare, our cases lend support to the
66
Figure 1 Average volume of isolated chylous ascites on the day of diagnosis (Index), the TCHM therapy is started (D0), and days after.
adoption of an additional approach to the management of chylous ascites in future. In previous studies, Kim et al.14 reported that the incidence of chylous ascites in left nephrectomy was higher than in right nephrectomy, which was also demonstrated in our cases (3/5 vs. 2/5). In addition, it was also reported that chylous ascites would occur on POD 5—12 when a normal diet was resumed. The drainage flow turned milky and/or the abdomen circumference slightly increased in patients without abdominal drainage.2 In our study, the chylous ascites started on POD 3—7. Currently, the treatment of chylous ascites remains controversial and mainly includes conservative management and surgery. The former usually includes salt restriction, diuretics and somatostatin,9,15,16 which all aim to reduce the lymphatic flow. Taking into consideration the fact that the amount of lymphatic flow relates to the fat content of the diet, in particular the long-chain triglycerides that make up approximately two-thirds of dietary fat, using a highprotein and low-fat diet with medium-chain triglycerides seems reasonable. But single diet control could result in consecutive drainage for up to 1 month.10 TPN may be also recommended either alone or with the chylous diet as a complementary therapy,7 but is usually costly and the central venous catheter poses a risk of infection.3,11 It is reported that 43—71% of patients would respond to conservative management and most of these cases could potentially be cured.9,10,17 Surgery is a salvage option when conservative management fails or lymphatic channel leak is detected in operation with a response rate of 58—100%.10,18 It is particularly recommended when leakage is sustained for more than 2 weeks, drainage volume reaches more than 1 l, even after 1 week, or the patient starts to experience metabolic complications.19 The standard surgical management is yet to be defined. However, it usually includes peritoneovenous shunts, imageguided sclerotherapy or surgical intervention with lymphatic duct ligation.2 Some authors advocate that surgical intervention can be performed as early as possible, but the majority of the research indicates that 2—8 weeks of observation is acceptable. Nevertheless, the optimal point for switching from conservative management to surgery has not been established.8,9,19
L. Xiu et al. In our study, 6 patients diagnosed with ‘‘Qi deficiency and dampness syndrome’’, were treated with diet control and TCHM of ‘‘strengthening-Qi and removing-dampness formula’’ and achieved a rapid recovery. Despite the limited data, we can speculate that some components in the TCHM may contribute to its efficacy. For example, Astragali Radix, the main herb in the decoction, has an effect on promoting wound healing and its underlying mechanisms are likely to contribute to its role in inhibiting endothelial cell apoptosis induced by Ang II, anti-inflammatory effect and relieving of microvascular insufficiency.20—22 In addition, Rosa laevigata Michx, Verbenae offcinalis L. and Saposhnikonia divaricata (Turcz.) Schischk were reported to have anti-inflammatory effects.23—25 Saposhnikonia divaricata (Turcz.) Schischk can inhibit the hyperpermeability of peritoneal capillary in mice induced by Hac.25 Coicis semen, Leonurus heterophyllus Sweet and Corn Stigma Stigma Maydis all have effects on improvement of the immune functions, such as promoting T lymphocyte proliferation.26—28 Nonetheless, we have to admit that no direct evidence is available at present to explain the efficacy of the TCHM. And we advocate more rigorous randomized controlled trials to confirm the role of TCHM in chylous ascites in the future.
Conflict of interest The authors have no conflicts of interest to declare.
Acknowledgement The study is supported with grants from Shanghai Municipal Health Bureau of China (no. ZYSNXD-CC-MZY054 to Professor Pinkang Wei).
References 1. Wu CW, Hsieh MC, Lo SS, Lui WY, P‘Eng FK. Results of curative gastrectomy for carcinoma of the distal third of the stomach. J Am Coll Surg 1996;183:201—7. 2. Kaas R, Rustman LD, Zoetmulder FA. Chylous ascites after oncological abdominal surgery: incidence and treatment. Eur J Surg Oncol 2001;27:187—9. 3. van der Gaag NA, Verhaar AC, Haverkort EB, Busch OR, van Gulik TM, Gouma DJ. Chylous ascites after pancreaticoduodenectomy: introduction of a grading system. J Am Coll Surg 2008;207:751—7. 4. Silk YN, Goumas WM, Douglass Jr HO, Huben RP. Chylous ascites and lymphocyst management by peritoneovenous shunt. Surgery 1991;110:561—5. 5. Bhat AL, Lowery GL. Chylous injury following anterior spinal surgery: case reports. Eur Spine J 1997;6:270—2. 6. Nagai H, Shimizu K, Shikata J, Iida H, Matsushita M, Ido K, et al. Chylous leakage after circumferential thoracolumbar fusion for correction of kyphosis resulting from fracture. Report of three cases. Spine (Phila Pa 1976) 1997;22:2766—9. 7. Ablan CJ, Littooy FN, Freeark RJ. Postoperative chylous ascites: diagnosis and treatment. A series report and literature review. Arch Surg 1990;125:270—3. 8. Combe J, Buniet JM, Douge C, Bernard Y, Camelot G. Chylothorax and chylous ascites following surgery of an inflammatory aortic aneurysm. Case report with review of the literature. J Mal Vasc 1992;17:151—6.
Chylous ascites treated by traditional Chinese herbal medicine 9. Leibovitch I, Mor Y, Golomb J, Ramon J. Chylous ascites after radical nephrectomy and inferior vena cava thrombectomy. Successful conservative management with somatostatin analogue. Eur Urol 2002;41:220—2. 10. Tulunay G, Ureyen I, Turan T, Karalok A, Kavak D, Ozgul N, et al. Chylous ascites: analysis of 24 patients. Gynecol Oncol 2012;127:191—7. 11. Ohri SK, Patel T, Desa LA, Spencer J. The management of postoperative chylous ascites. A case report and literature review. J Clin Gastroenterol 1990;12:693—7. 12. Liu YH, Cui Y, Hui N, Xu MJ, Han QF. Protection effect of traditional Chinese medcine on post-hysterectomy urinary retention. J Second Mil Med Univ 2000:763—4. 13. Zhang Z, Liu Y, Zhang WL, Wang W, Wang WY, Fu S. 32 cases of colon cancer patients presenting postoperative gastrointestinal dysfuntion were treated with Jiawei Sanxiang granules. Tradit Chin Med 2013;54:966—7. 14. Kim BS, Yoo ES, Kim TH, Kwon TG. Chylous ascites as a complication of laparoscopic nephrectomy. J Urol 2010;184:570—4. 15. Baniel J, Foster RS, Rowland RG, Bihrle R, Donohue JP. Management of chylous ascites after retroperitoneal lymph node dissection for testicular cancer. J Urol 1993;150:1422—4. 16. Manolitsas TP, Abdessalam S, Fowler JM. Chylous ascites following treatment for gynecologic malignancies. Gynecol Oncol 2002;86:370—4. 17. Frey MK, Ward NM, Caputo TA, Taylor J, Worley Jr MJ, Slomovitz BM. Lymphatic ascites following pelvic and paraaortic lymphadenectomy procedures for gynecologic malignancies. Gynecol Oncol 2012;125:48—53. 18. Browse NL, Wilson NM, Russo F, al-Hassan H, Allen DR. Aetiology and treatment of chylous ascites. Br J Surg 1992;79:1145—50.
67 19. Merrigan BA, Winter DC, O’Sullivan GC. Chylothorax. Br J Surg 1997;84:15—20. 20. Jinye Song, Liqiang Meng, Shen Li LQ, Li X. A combination of Chinese herbs, Astragalus membranaceus var. mongholicus and Angelica sinensis, improved renal microvascular insufficiency in 5/6 nephrectomized rats. Vascul Pharmacol 2009;50:185—93. 21. Lee DY, Noh HJ, Choi J, Lee KH, Lee MH, Lee JH, et al. Anti-inflammatory cycloartane-type saponins of Astragalus membranaceus. Molecules 2013;18:3725—32. 22. Liang LS, Yu J, Song RX, He XH, Chang P, Wang HQ. The protective effect of Gansu Astragalus flavonoids on apoptosis of endothelial cell induced by Ang II. Chin Pharmacol Bull 2006;22:1505—9. 23. Wang Y, Yang J, Li ZX, Wang S, Tian ZY. The comparative study on anti-inflammatory effect of Rosa laevigata Mickx roots and its stems. Mod Chin Med 2010;12:34—5. 24. Yang HG, Fang LH, Du GH. Pharmacological activities and clinical application of Verbenae offcinalis. Chin Pharm J 2013;48:949—52. 25. Li W, Li L, Liu YY, Yin XJ, Xiao YQ. Experimental study of pharmacological action of active composition of Radfx Saposhnikovia. Chin J Exp Tradit Med Formulae 2006;12:29—31. 26. Wu Y, Yuan YF. Advance in studies on chemical components and pharmacological effect of Semen Coicis. West Pharm J 2010;25:111—3. 27. Xu HM, Li ZM, Han BM, Zhang XM. The effect on T and B lymphocytes of prehispanolone. Chin Tradit Patent Med 1992;27:812—6. 28. Ye SY, Gao W. Advance in studies on Corn Stigma Stigma Maydis. Chin Tradit Patent Med 2008;30:745—8.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevierhealth.com/journals/ctim
CASE REPORT
Chylous ascites treated by traditional Chinese herbal medicine: A case report and discussion Lijuan Xiu 1, Bing Yan 1, Zhifeng Qin, Xuan Liu, Feng Wu, Xiaowei Wang, Pinkang Wei ∗ Department of Traditional Chinese Medicine, Chang Zheng Hospital, the Second Military Medical University, Shanghai 200003, China Available online 14 October 2014
KEYWORDS Chylous ascites; Postoperative complications; Traditional Chinese herbal medicine
Summary Chylous ascites, which can lead to peritonitis, intestinal obstruction, metabolic disorder, and even death from pyemia, is a rare complication of abdominal surgery. Currently, first-line treatment involves conservative management, which includes oral diet and total parenteral nutrition (TPN). However, the efficacy of these treatments cannot be guaranteed. For example, single diet control can result in consecutive drainage for up to 1 month, and salvage surgery is required for some invalid cases. Here, we report 6 cases of chylous ascites after abdominal surgery. In addition to diet control, we delivered traditional Chinese herbal medicine (TCHM) twice daily orally. The drainage volume of the chylous fistula showed an obvious decrease 1 day after the TCHM administration and all 6 patients completely recovered within 4 to 8 days (median: 5.5 days). Although relevant data are limited, our cases would suggest that TCHM could play an important role in the management of chylous ascites. However, randomized controlled trials are still needed to confirm its efficacy in a larger population. © 2014 Elsevier Ltd. All rights reserved.
Introduction It is well established that chylous ascites is a rare complication of various abdominal surgeries, with an incidence at
∗ Corresponding author at: Head of Department of Traditional Chinese Medicine Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai 200003, China. Tel.: +86 2181885476; fax: +86 2163520020. E-mail address: [email protected] (P. Wei). 1 These authors contributed equally to this work.
http://dx.doi.org/10.1016/j.ctim.2014.10.006 0965-2299/© 2014 Elsevier Ltd. All rights reserved.
about 5—11%.1—3 It can result in poor prognosis for these patients due to complications such as peritonitis, intestinal obstruction, metabolic disorder, prolonged hospital stay, and even death from pyemia.3—6 The underlying mechanism of the disease is conventionally attributed to the extensive loss of lymph nodes after resection which can lead to inadequate drainage, congested upstream lymph ducts,7 especially for those who experience operative trauma to cisterna chyli or retroperitoneal lymphatic vessels after retroperitoneal surgery.7—9 Aggressive lymphadenectomy in the para-aortic region was also regarded as a risk factor for chylous ascites.10 The main treatment approach for chylous
64 Table 1
L. Xiu et al. Ingredients and the corresponding percent of TCHM.
Chinese name
Common name
Latin name
Percent (%)
Huang Qi Yi Yi Ren Qian Shi Yu Mi Xu Yi Mu Cao Fang Feng Ma Bian Cao Jin Ying Zi Zhe Bei Mu Gan Cao
Milkvetch Root Semen Coicis Gorgon Euryale Seed Corn silk Herba Leonuri Radix Saposhnikoviae Herba Verbenae Offcinalis Fructus Rosae Laevigatae Fritillaria thunbergii Glycyrrhiza
Astragali Radix Coicis semen Semen Euryales Corn Stigma Stigma Maydis Leonurus heterophyllus Sweet Saposhnikonia divaricata (Turcz.) Schischk Verbenae Offcinalis L. Rosa Laevigata Michx Fritillariae Thunbergii Mig Radix Glycyrrhizae praeparatae
25 12.5 12.5 12.5 12.5 6.25 6.25 6.25 4.17 2.08
ascites is conservative management, aimed at reducing the lymph leak of injury retroperitoneal lymphatic.9 However, the efficacy of these treatments cannot be guaranteed. In recent years, traditional Chinese herbal medicine (TCHM) has increasingly proved to be effective in management of the postoperative complications, such as postoperative urinary retention and gastrointestinal dysfunction.12,13 However, there is no data on its role on chylous ascites. Here, we report our experience with 6 patients who underwent abdominal surgery and presented with postoperative chylous ascites. In addition to diet control, we administered TCHM after the confirmation of chylous ascites. The composition and proportions of the herbs are described in Table 1. The drainage volume of the chylous fistula showed a marked decrease 1 day after the administration of TCHM and all 6 patients completely recovered in 4 to 8 days (median: 5.5 days).
Case presentation Six patients with postoperative chylous ascites were refereed to Shanghai Changzheng Hospital, Shanghai, China from October 2011 to December 2012 (Table 2). Table 2
Case 1 A 59-year-old man presented with an obscure adrenal gland lesion and underwent a right laparoscopic adrenalectomy in 2011. After surgery, the volume of drainage was approximately 160 ml per 24 h. On the postoperative day (POD) 7, chylous ascites occurred, the patient’s tongue being pale with thin and greasy coating, and pulse being smooth. The patient was then treated with albumin, a low-fat diet and TCHM. The drainage volume immediately decreased to 87 ml/24 h, and was further reduced to 15 ml/24 h 2 days later. After that, the drains were removed and no other complications occurred.
Case2 A 68-year-old woman was diagnosed with renal cancer and underwent a left laparoscopic radical nephrectomy in 2011. The volume of drainage decreased gradually after the surgery, but increased to approximately 140 ml/24 h on POD 5 with no obvious cause. A chyle test was positive and chylous ascites was confirmed. She presented a pale tongue with thin and greasy coating, and rapid pulse. The patient was
Clinical profile of patients in whom chylous fistula developed.
Patient no.
Age
Gender
Primary site
Surgery
Biochemically proved
1
59
Male
Right laparoscopic adrenalectomy
No
2
68
Female
Right adrenal gland occupying lesion Left renal cancer
Yes
3
49
Female
Right renal cancer
4
47
Male
5
63
Male
Left non-functioning kidney Left ureteral cancer
6
57
Male
Left laparoscopic radical nephrectomy Right partial nephrectomy Left laparoscopic radical nephrectomy Left laparoscopic nephroureterectomy Cystectomy
Bladder cancer recurrence
Yes Yes
No
No
Chylous ascites treated by traditional Chinese herbal medicine Table 3
65
Management of chyle leak.
Patient no.
Type of management
Onset of chylous ascites
Average drain output (ml)
Termination of chyle leak (POD)
1 2 3 4 5 6
Low-fat Low-fat Low-fat Low-fat Low-fat Low-fat
Day Day Day Day Day Day
61 109 123 96 127 300
4 7 8 8 4 4
diet + albumin + TCM diet + TCM diet + albumin + TCM diet + TCM diet + TCM diet + albumin + TCM
5 5 7 4 5 3
simultaneously administrated a low-fat diet and TCHM. Her volume of drainage decreased to 45 ml/24 h 2 days later, and at this point the patient recovered and no other complications were reported.
greasy coating, and soft-superficial and smooth pulse. The patient received a low-fat diet, albumin and TCHM. The volume of fluid in drainage was then decreased to 50 ml/24 h 2 days later, and no other complications presented during the follow-up.
Case 3 A 49-year-old woman was diagnosed with renal cancer and underwent a right partial nephrectomy in 2011. Similar to Case 2, she presented chylous ascites on POD 5 (approximately180 ml/24 h), with no obvious cause. She presented a pale tongue with thin and greasy coating, and thread pulse. The patient was simultaneously administrated a low-fat diet, albumin and TCHM. The volume of drainage decreased to 40 ml/24 h 6 days later, and no other complications were detected in the follow-up.
Case 4 A 47-year-old man was diagnosed with a non-functioning kidney and underwent left laparoscopic radical nephrectomy in 2011. The discharge (approximately 155 ml/24 h) turned milky on POD 4 and the chyle test was positive. He presented a pale and swollen tongue with thin, white and greasy coating, and smooth pulse. The patient received a low-fat diet and TCHM. The volume of fluid in drainage was decreased to 30 ml/24 h 6 days later, and no other complications were recorded.
Case 5 A 63-year-old man was diagnosed with ureteral cancer and underwent left laparoscopic nephroureterectomy in 2012. The discharge of 260 ml/24 h turned milky on POD 5 and chylous ascites was confirmed. He presented a pale and swollen tongue with thick, white and greasy coating, and soft-superficial pulse. The patient immediately received a low-fat diet and TCHM. The volume of fluid in drainage was then decreased to 50 ml/24 h 6 days later, and no other complications were detected in the follow-up.
Case 6 A 57-year-old man presented with cystectomy due to a recurrence of bladder cancer in 2012. The discharge increased on POD 3 (approximately 340 ml/24 h). He presented a pale and swollen tongue with thick, white and
Syndrome differentiation According to the principle of traditional Chinese medicine (TCM), the Qi deficiency could be occurred in some wound situation (including surgery) since the majority of the patients would lost this important element in these processes. Taking into consideration of the role of Qi deficiency in TCM, it would be predictable that it could lead to some symptoms like fluid retention as well as delay the time of healing when it was happened. The patients’ pale or/and swollen tongue with thin or thick greasy coating combined with smooth or soft-superficial pulse accorded with Qi deficiency and dampness syndrome. Indeed, the therapeutic principle of TCM is strengthening Qi and removing dampness. In all 6 cases, chylous leakage was confirmed by the detection of milky fluid in drainage tubes or a drainage volume that was more than 200 ml/day,10 and/or drainage that proved biochemically positive. Once chylous ascites was confirmed, all the patients were treated by conservative management and TCHM 1—2 days later (Table 3), 150 ml per time at a frequency twice a day orally. The treatments were administrated until the drains were discharged. All the herbs were purchased from Cai Tongde Pharmacy Co. Ltd (Shanghai, China) and therefore had a definite origin and were of good quality. For all the patients, the drains were removed when the discharge decreased to 50 ml/24 h. As shown in Fig. 1, the average chylous leakage increased dramatically when single conservative management was adopted, but then markedly decreased once the TCHM treatment was initiated. After 4—8 days’ (median: 5.5 days) treatment, all the patients recovered and no other complications were detected in the follow-up.
Discussion In current study, we presented 6 cases of chylous ascites that were mainly treated with a single treatment as part of a conservative management approach and TCHM. We observed a marked decrease in drainage volume and a short recovery time (4—8 days) compared to previously reports. Although related data are still rare, our cases lend support to the
66
Figure 1 Average volume of isolated chylous ascites on the day of diagnosis (Index), the TCHM therapy is started (D0), and days after.
adoption of an additional approach to the management of chylous ascites in future. In previous studies, Kim et al.14 reported that the incidence of chylous ascites in left nephrectomy was higher than in right nephrectomy, which was also demonstrated in our cases (3/5 vs. 2/5). In addition, it was also reported that chylous ascites would occur on POD 5—12 when a normal diet was resumed. The drainage flow turned milky and/or the abdomen circumference slightly increased in patients without abdominal drainage.2 In our study, the chylous ascites started on POD 3—7. Currently, the treatment of chylous ascites remains controversial and mainly includes conservative management and surgery. The former usually includes salt restriction, diuretics and somatostatin,9,15,16 which all aim to reduce the lymphatic flow. Taking into consideration the fact that the amount of lymphatic flow relates to the fat content of the diet, in particular the long-chain triglycerides that make up approximately two-thirds of dietary fat, using a highprotein and low-fat diet with medium-chain triglycerides seems reasonable. But single diet control could result in consecutive drainage for up to 1 month.10 TPN may be also recommended either alone or with the chylous diet as a complementary therapy,7 but is usually costly and the central venous catheter poses a risk of infection.3,11 It is reported that 43—71% of patients would respond to conservative management and most of these cases could potentially be cured.9,10,17 Surgery is a salvage option when conservative management fails or lymphatic channel leak is detected in operation with a response rate of 58—100%.10,18 It is particularly recommended when leakage is sustained for more than 2 weeks, drainage volume reaches more than 1 l, even after 1 week, or the patient starts to experience metabolic complications.19 The standard surgical management is yet to be defined. However, it usually includes peritoneovenous shunts, imageguided sclerotherapy or surgical intervention with lymphatic duct ligation.2 Some authors advocate that surgical intervention can be performed as early as possible, but the majority of the research indicates that 2—8 weeks of observation is acceptable. Nevertheless, the optimal point for switching from conservative management to surgery has not been established.8,9,19
L. Xiu et al. In our study, 6 patients diagnosed with ‘‘Qi deficiency and dampness syndrome’’, were treated with diet control and TCHM of ‘‘strengthening-Qi and removing-dampness formula’’ and achieved a rapid recovery. Despite the limited data, we can speculate that some components in the TCHM may contribute to its efficacy. For example, Astragali Radix, the main herb in the decoction, has an effect on promoting wound healing and its underlying mechanisms are likely to contribute to its role in inhibiting endothelial cell apoptosis induced by Ang II, anti-inflammatory effect and relieving of microvascular insufficiency.20—22 In addition, Rosa laevigata Michx, Verbenae offcinalis L. and Saposhnikonia divaricata (Turcz.) Schischk were reported to have anti-inflammatory effects.23—25 Saposhnikonia divaricata (Turcz.) Schischk can inhibit the hyperpermeability of peritoneal capillary in mice induced by Hac.25 Coicis semen, Leonurus heterophyllus Sweet and Corn Stigma Stigma Maydis all have effects on improvement of the immune functions, such as promoting T lymphocyte proliferation.26—28 Nonetheless, we have to admit that no direct evidence is available at present to explain the efficacy of the TCHM. And we advocate more rigorous randomized controlled trials to confirm the role of TCHM in chylous ascites in the future.
Conflict of interest The authors have no conflicts of interest to declare.
Acknowledgement The study is supported with grants from Shanghai Municipal Health Bureau of China (no. ZYSNXD-CC-MZY054 to Professor Pinkang Wei).
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