Case reports

reported cases all following abdominal aortic aneurysm repair' -5. This is the first case reported following aortofemoral bypass. Bradham et a/.' in 1970 described chylous ascites which developed after abdominal aneurysm repair and which did not respond to conservative treatment. At operation, closure of multiple small fistulae was curative.

are similar. Most patients presented 2 4 weeks after abdominal aortic aneurysm repair and the diagnosis was accomplished by paracentesis. Chylous ascites will separate into layers on standing, is odourless or may have the odour of digested food. The specific gravity is usually greater than 1.012, the fluid it is usually alkaline and sterile and contains > 4 per cent total solids. An increased fat content from 4-40g/l may give a positive Sudan I11 stain. Total protein content is at least half that of plasma6.

Chylous ascites has also been reported following operations such as pancreaticoduodenectomy7, truncal vagotomy', retroperitoneal l y m p h a d e n e c t ~ m y ~ * ' ~ and Warren distal- splenorenal shunt'' - 12. It is aggravated by pre-existing liver

No case in the recent literature has resulted in death.

The danger of prolonged intra-abdominal lymph leak is nutritional wasting secondary to excess protein loss and fat malabsorbtion. Meinke et d4 suggested that surgery be performed early with preliminary oral alimentation or parenteral hyperalimentation for nutritional support.

Our treatment protocol is as follows (see Figure I). Paracentesis is performed for diagnosis and appropriate laboratory evaluation. A patient who is a good operative candidate and is nutritionally replete should have a lymphangiogram followed shortly by laparotomy to close the fistula.

Conventional lymphangiography by injection at the foot may not visualize the intra-abdominal lymph fistula and pre- operative feeding of cream containing a vital dye such as Sudan Black or intra-operative injection of a vital dye into the small bowel mesentery may be preferable' 3*1 ' . A negative pre- operative lymphangiogram should not contraindicate surgical repair.

A patient who is a good operative candidate, but who is not nutritionally replete should have nutritional supplements (preferably hyperalimentation with or without elemental feeds) followed by operative repair once his status improves. A patient who is a poor operative risk and who is nutritionally replete should be treated conservatively with a low fat diet, supplemented with medium chain triglycerides, repeat paracentesis, diuretics and bed rest until their status improves sufficiently to permit laparotomy. Poor risk patients who are not nutritionally replete should be treated with hyperalimentation paracentesis as necessary, bed rest and diuretics until they will tolerate operation. Finally, those patients who fail to close their fistula despite operation or who cannot tolerate laparotomy become candidates for peritoneal-venous shunt, a procedure that has proved useful in several case~ '~, ' ' .

The subsequent four

Br. J. Surg. 1987, Vol. 74, January, 71 -72

Chylous ascites following aortic surgery

C. Williamson and J. L. Provan

Department of Surgery, Division of Vascular Surgery, The Wellesle y Hospital, University of Toronto, Toronto, Ontario M4Y 7J3, Canada Correspondence to: Dr J. L. Provan, Suite 217, E.K. Jones Building, 160 Wellesley St. East, Toronto, Ontario M4Y 1 J3. Canada

Persistent lymph leak leading to ascites following aortic repair is extremely uncommon and chylous ascites following aortofemoral bypass has not previously been described. Conservative and operative management are discussed and a management protocol for this uncommon complication is proposed.

Case report A 65-year-old man was admitted to hospital with a three-week history of gangrene of the left great toe. His past history included bilateral femoropopliteal bypasses and a right iliac endarterectomy performed several years earlier. He had an infection in the right groin following the right femoropopliteal bypass.

Angiography showed complete occlusion of the left common iliac artery, of both fernoropopliteal bypasses and a severely diseased left profunda femoris artery. He underwent a left aortofemoral bypass graft and an extended left profundaplasty using an 8mm knitted Cooley Dacron graft through a transabdominal approach and was discharged on the tenth postoperative day without complication and with a warm, pain-free foot.

Six weeks later he was readmitted with a 2 week history of left leg and abdominal swelling and weight loss. He was found to have ascites and underwent paracentesis of more than 7 litres of turbid fluid. On examination he was afebrile, displayed marked ascites and showed pitting oedema from the left ankle to the mid-thigh. There was no clinical evidence of venous thrombosis and he was not in congestive heart failure.

Laboratory data on admission showed a normal serum amylase, liver function tests, and coagulation profile. His haemoglobin on admission was 14.9 g/dl. Total serum proteins were 55 g/l (normal 52-84) and serum albumin was 27g) (normal 35-50). Ultrasound of the abdomen revealed a large amount of peritoneal fluid and a fluid collection in the left groin.

Paracentesis demonstrated cloudy yellow, odourless fluid which separate into layers on standing. Laboratory examination of the'fluid revealed a total protein content of 21 g/l. Cytology showed no malignant cells and there were no bacteria. A diagnosis of chylous ascites was made. A lymphangiogram with an oil-based dye showed obstruction of lymph flow in the left iliac area, but no intra-abdominal leak of lymph. The patient was started on a low fat elemental diet by mouth with a medium chain triglyceride fatty supplement. His ascites continued to accumulate and his serum albumin to fall. On the twelth hospital day an exploratory laparotomy was performed. Immediately before operation, methylene blue was injected into the web spaces of both feet. Seventeen litres of ascites were drained and a lymph leak was noted in the area of the ligament of Treitz. This area was oversewn with Dexon sutures and an omental flap placed. No methylene blue dye was seen. Postoperatively he was started on total parenteral nutrition with cessation of oral feedings for four weeks. Oral feeding was started in the fifth week and he was discharged one week later with normal serum proteins, no ascites and in good health.

Discussion Chylous ascites is a very rare complication of abdominal aortic surgery. Literature review has revealed only five previously

Continued Pwr Operative Candiddle Nutritional Status GoMl b

Continued pmr operative

LOW 111 d l d medium chain triglyrerider

m I

-- Figure 1 Treatment protocol for patients with chylous ascites

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Case reports

References 1.

2.

3.

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8.

9.

Bradham RR, Gregone HB, Wilson R. Chylous ascites following resection of an abdominal aortic aneurysm. Am Surgeon 1970; 36 23840. Ddbartolo TF, Etzkorn JR. Conservative management ofchylous ascites after abdominal aortic aneurysm repair. Missouri Medicine

Stubbe FL, Terpstra JL. Chylous ascites after resection of an abdominal aortic aneurysm. Archivum Chirurgicum Neerlaudicum 1979; 31: 111-13. Meinke AH, Estes NC, Ernst CB. Chylous ascites following abdominal aortic aneurysmectomy: management with total parenteral hyperalimentation. Ann Surg 1979; 190: 631-3. Klippel AP and Hardy DA. Postoperative chylous ascites. Missouri Med 1971; 68: 253-5. Vasko JS, Tapper RI. Surgical significance ofchylous ascites. Arch Surg 1967; 95: 355. Walter WM. Chylous ascites following pancreatico- duodenectomy. Arch Surg 1967; 95 640-41. Hocking MA, Barth CE. Chylous ascites: a complication of vagotomy. J R Coll Surg Edin 1978; 23: 232-3. Bigley HA Jr, Chenoult O W Jr. Chylous ascites following retroperitoneal lymphadenectomy. J Urol 1975; 114 948-50.

1976; 7 3 611-13.

10.

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Jansen TTH, Debruyne FMJ, Delaere KPJ, Devries JDM. Chylous ascites after retroperitoneal lymph node dissection. Urology 1984; 23: 565-7. Freund H, Brewster D, Fischer JE. Total parenteral nutrition in post-Warren shunt chylous ascites (Letter). Arch Surg 1979; 114 345. Maywood BT, Goldstein L, Busuttil RW. Chylous ascites after a Warren shunt. Am J Surg 1978; 135: 70e-702. Pearl J, Joyner J, Collins DL. Chylous ascites: the first reported surgical cure by direct ligation. J Ped Surgery 1977; 12: 687-91. Rector WG. Spontaneous chylous ascites of cirrhosis. J Cf in Gastroenterol 1984; 6: 369-72. Malagelada JR, Iber FL, Linscheer WG. Origin of fat in chylous ascites in patients with liver cirrhosis. Gastroenterology 1974; 67 878-86. Rubis PJ, Tisnado J, Kirsch JI, Capehard J. Intraoperative identification of chylous fistula using isosulphan blue dye. Am J Rad 1982; 139 186-7. Ryan JA Jr, Smith MD, Page CP. Treatment of chylous ascites with peritoneovenous shunt. A m Surg 1981; 4 7 384-6. Turner WW Jr. Chylous ascites: resolution after denver peritoneovenous shunt. South Med J 1983; 7 6 539.

Paper accepted 30 July 1986

Br. J. Surg. 1987, Vol. 74, January, 72

Calculous disease of a primary vaginal hydrocele in an infant

S. E. E. Efem University Department of Surgery, University Teaching Hospital, Cala bar, Nigeria Correspondence to: MIS. E. E. Efem

Calcium deposits have been described in the tunica vaginalis and on the surface of the testis in up to 20 per cent ofhydroceles', but the occurrence of stones in a hydrocele sac has not been previously reported.

Case report A 6-month-old male infant presented at the University of Calabar Teaching Hospital with a 2 month history of a swollen right saotum. This swelling appeared spontaneously and had been increasing steadily in size. It was painless and the child had showed no symptoms referable to the swelling. It did not reduce in size when the child was recumbent nor did it increase in size on crying or straining during defaecation.

The child was the first baby of a working class young couple. He was delivered at term. Gestation and perinatal periods were uneventful and developmental milestones were normal.

Examination revealed an otherwise well looking and fit child with a tense non-tender brilliantly transillurninant swelling about the size of a hen's egg in the right sac. The right testis was not palpable and the swelling was confined to the scrotum. The swelling was irreducible and there were no bowel sounds on auscultation.

At operation the swelling was explored by an inguinal approach; no hernial sac was present. The hydrocele fluid whose volume was about 50 ml, was straw coloured. Nineteen greyish white stones were found within the hydrocele sac (Figure I ) . The stones were firm but not hard and were about the size of peanuts. No organisms were cultured from the fluid and no parasites were isolated; on chemical analysis, the stones were composed of calcium oxalate, calcium phosphate and magnesium phosphate. Serum calcium was normal and there was no laboratory or clinical evidence of hyperparathyroidism.

Discussion This patient is unique. The stones have all the features of primary urinary calculi. There were no bacteria, epithelial debris, fibrin or foreign body in the core and all were of uniform consistency and constituents. There was no evidence of communication between the tunica vaginalis and the urinary system or even the peritoneal cavity.

This is the first recorded case of primary stones of the tunica vaginalis.

Figure 1 expose 19 calculi surrounding the testis

Right vaginal hydrocele opened through a groin incision to

Acknowledgements I wish to thank Professor 1 .0 . K. Udozor and the staff of the Chemical Pathology and Microbiology Laboratories of the University of Calabar Teaching Hospital for analysing the stones.

References 1. Dandapat MC, Mohapatro SK, Mohanty SS. The incidence of

FiIaria as an aetiological factor for testicular hydrocele. Br J Surg 1986; 7 3 77-8.

Paper accepted 30 July 1986

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