Case Presentation: A 68-year-old man presented with worsening abdominal distention, lower extremity edema and shortness of breath 8 weeks after undergoing uneventful aortobifemoral bypass graft (AFBG). The patient was cachectic man, who had significant abdominal distention from ascites confirmed with ultrasound, right lung dullness with decreased air entry due to pleural effusions and bilateral lower extremity edema up to the thighs. Liver function, basic metabolic panel, urine analysis and echocardiogram were within normal range. He underwent paracentesis with removal of 5.2 L of milky fluid. Fluid analysis revealed significantly elevated triglycerides of 2034 mg/dL. Ascitic fluid cytology was negative for malignant cells and infection. Serum-ascites albumin gradient (SAAG) was found to be low at 0.3. A thoracentesis was performed and 900 mL of milky fluid was drained from the right pleural space. Pleural fluid analysis showed elevated triglycerides of 242 mg/dL consistent with a diagnosis of chylothorax.
The patient improved clinically after fluids removal and was started on furosemide and spironolactone titrated to 40 mg and 100 mg daily, respectively. He was also started on a low-fat, high-protein and medium chain fatty acid diet. Diuretics were discontinued at two month follow-up, with no recurrence of ascites or pleural effusion.
Discussion: A few cases of chylous ascites following aortic aneurysm surgeries are discussed in the literature but this is a rare case of both chylothorax and chyloperitoneum developing after AFBG surgery. Early recognition and initiation of appropriate management is challenging. Anatomy of the thoracic duct determines the location of the effusion. The disruption injury to the intraabdominal portion of the thoracic duct can cause chyloperitoneum that passes through the diaphragm resulting in a chylothorax.
Evidence-based guidelines are lacking to provide the best treatment options in a patient with chylous effusions and chyloperitoneum. After diagnosis, treatment should focus on drainage, adherence to a low-fat diet, and supplementation with medium-chain triglycerides. Chylous effusions are associated with mortality of up to 50%, but conservative management can reduce complications to 10%. Location of lymphatic disruption via lymphangiography and therapeutic embolization may be useful for the evaluation and treatment of refractory postoperative chylothorax and chyloperitoneum.
Conclusions: We report a rare case of chyloperitoneum and chylothorax after AFBG surgery. Early recognition and treatment can prevent complications. We recommend conservative management with drainage, judicious use of diuretics, adherence to a low-fat diet, and supplementation with medium-chain triglycerides.