Chylous leak following laparoscopic distal gastrectomy with D2 dissection for a locally advanced, distal obstructive gastric cancer

The lymphatic system was first described by Asellius in 1627, and chylous leak (CL) was first reported by Morton in 1691 [1, 2]. It is defined as the leakage of milk-like, triglyceride-rich lymphatic fluid from the lymphatic system in to the peritoneal cavity [3]. It can cause fever, abdominal pain, abdominal distension, and abnormal white blood cell count and a delay in the withdrawal of the abdominal drainage tube. Even more serious, improper treatment will lead to celiac infection and abdominal bleeding, which results in prolonged hospitalization and increased costs. The incidence of CL after gastrectomy with D1–2 dissection is reported as 1.99%; however, D3–4 lymphadenectomy is associated with a higher incidence of CL of up to 6.3% [4], indicating that locally advanced diseases and extensive lymph node dissection lead to a higher incidence of CL. Laparoscopic gastrectomy (LAG) with lymphadenectomy has recently been accepted as a safe and effective surgical treatment for gastric cancer [5]. There have been very few reports focused on CL after LAG [3] and D1-D2 dissection [6, 7], especially in locally advanced and semi-elective cases.

A 62-year-old male presented with complaints of nausea, vomiting, decreased appetite, and significant weight loss for 3 months. He had no history of additional disease or previous abdominal surgery. His body mass index was 18 kg/m 2 , and his Eastern Cooperative Oncology Group (ECOG) performance status was 1.

In the laboratory evaluation, haemoglobin was 12 g/dl, platelet count 272,000/ml, albumin 3.4 g/dl, total protein 6.2 g/dl, and tumour markers were normal. Upper gastrointestinal endoscopy revealed a stomach filled with solid food debris and a mass protruding from the antropyloric region of the stomach, which did not allow the passage of the scope (Figure 1). Endoscopic biopsy report of the mass showed high-grade dysplasia. Contrast-enhanced thorax, abdomen, and pelvis computer tomography showed clinical T3N+M0 gastric cancer (Figures 2 A–C). The patient was optimized for surgery and later underwent laparoscopic distal gastrectomy with D2 dissection and gastrojejunostomy with Roux-en-Y reconstruction. Intraoperatively, there were no adhesions, ascites, or omental deposits. Three 16 french, silicone drains were placed: one in the foramen of winslow, one behind the gastroenterostomy, and one in the pelvis.

In the macroscopic evaluation of the surgical specimen, an ulcerovejatan...


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