title: Refractory hepatic lymphorrhea after total pancreatectomy. Case report and literature review of this uncommon complication.
abstract: BACKGROUND
  After extended abdominal lymphoadenectomy, lymphatic vessel injury may cause lymphorrhea that usually disappears spontaneously. However, intractable ascites sometimes develops. Although there are many reports describing persistent chylous ascites from intestinal lymphorrhea, little is known about hepatic lymphorrhea, not containing chyle. It is caused by injury of the lymphatic vessels during hepatoduodenal ligament lymphadenectomy. We present a case of massive ascites due to hepatic lymphorrhea after total pancreatectomy and extended lymhoadenectomy for Ampullar adenocarcinoma. We successfully treated it with prolonged medical therapy after surgical relaparotomy.
  
  
  METHODS
  A 65-year old man underwent total pancreatectomy with extended nodal dissection. Massive clear-colored ascites (2000-9000mL per day) developed since the second postoperative day and persisted despite conservative therapy. At re-laparotomy no lymphatic leakage was found. Similarly lymphangiography was showed no contrast spreading. We treated this hepatic lymphorrea with intermittent opening of the abdominal drainage until spontaneous resolution.
  
  
  CONCLUSIONS
  The standard treatment of hepatic lymphorrhea is an aggressive medical treatment. After such approach the most effective therapy seems to be surgical exploration. Other option are peritoneovenous shunt or intraperitoneal administration of OK-432.
  
  
  CONCLUSIONS
  In our experience the intermittent abdominal drainage until spontaneous resolution is an useful approach to hepatic lymphorrhea.
authors.affiliation: Department of Medical and Surgical Sciences, Surgical Clinic, University of Brescia, Brescia Civil Hospital, P.le Spedali Civili, 1, 25123 Brescia, Italy. Electronic address: michelebartoli83@gmail.com.
authors.forename: Michele
authors.initials: M
authors.lastname: Bartoli
authors.affiliation: Department of Medical and Surgical Sciences, Surgical Clinic, University of Brescia, Brescia Civil Hospital, P.le Spedali Civili, 1, 25123 Brescia, Italy.
authors.forename: Gian Luca
authors.initials: GL
authors.lastname: Baiocchi
authors.affiliation: Department of Medical and Surgical Sciences, Surgical Clinic, University of Brescia, Brescia Civil Hospital, P.le Spedali Civili, 1, 25123 Brescia, Italy.
authors.forename: Nazario
authors.initials: N
authors.lastname: Portolani
authors.affiliation: Department of Medical and Surgical Sciences, Surgical Clinic, University of Brescia, Brescia Civil Hospital, P.le Spedali Civili, 1, 25123 Brescia, Italy.
authors.forename: Stefano Maria
authors.initials: SM
authors.lastname: Giulini
keywords: Chylous ascites; Hepatoduodenal ligament; Lymphadenectomy; Lymphangiography; Refractory hepatic lymphorrhea