Journal Reading

“Octreotide therapy for the management of refractory

chylous ascites after a staging operation for
endometrial adenocarcinoma”
Eun Ah Kim, Hyun Park, Sang Geun Jeong, Chan Lee, Joon Mo Lee and Chong Taik Park

Supervisor:
Dr. dr. Muh Darwin Prenggono, Sp.PD, K-HOM, FINASIM

By : Ciptadi Iqbal

Internal Medicine Residency Program – IIB

Ulin Hospital/Faculty of Medicine
Lambung Mangkurat University
 ABSTRACT
• Chylous ascites after para-aortic
lymphadenectomy is caused by a
rupture in the retroperitoneal lymphatic
channels.
• The incidence of postoperative chylous
ascites is increasing as para-aortic
lymphadenectomy for the management
of gynecologic malignancies becomes
more common.
• However, management of this condition
remains unsatisfactory because some
patients do not respond to conservative
methods and have to undergo surgical
intervention, even though they may be
malnourished and immunosuppressed.
 ABSTRACT
• We report the case of a patient who underwent a standard staging operation for
endometrial cancer and experienced a large amount of lymphatic leakage, in spite
of treatment with total parenteral nutrition and a low-fat diet for over 40 days. As
a step-up approach, octreotide, a somatostatin analog, was added and the
disease resolved completely.
• This case demonstrated that octreotide therapy is highly effective in refractory
cases of chylous ascites where a large amount of leakage is observed and cases
that are otherwise indicated for surgical intervention.

Key words: chylous ascites, diet, lymphadenectomy, octreotide, parenteral nutrition

 INTRODUCTION
• Chylous ascites is defined as the abdominal cavity accumulation of a fluid that
appears milky because of high chylomicron content. The fluid contains
protein,triglyceride, and lymphocytes that leak from the lymphatic channels
that are connected with the gastrointestinal tract.
INTRODUCTION
• Parenteral nutrition or a low-fat
diet, as a first step, are expected
to reduce lymphatic production,
decrease the flow, and induce the
coaptation of the ruptured
lymphatics. Some patients follow
a protracted course and
experience mechanical,
nutritional, and immunological
effects.
 INTRODUCTION
• Recently, somatostatin was found to be
highly effective in patients with highoutput • Octreotide is a medication used in the
lymphatic leakage, as it cause contraction of management and treatment of
the lymphatic vessels acromegaly and thyrotrophinomas. It is
in the somatostatin analog class of drugs
 INTRODUCTION
Algorithm
Management of
Chylous Ascites
 CASE REPORT
• A 43-year-old woman developed chylous
ascites after total laparoscopic
hysterectomy and para-aortic and pelvic
lymph node dissection for well-
differentiated endometrioid
adenocarcinoma of the uterine
endometrium. During lymphadenectomy,
ruptured lymphatic vessels were secured
to prevent lymphatic. leakage.
• Para-aortic lymph nodes were removed
up to the level of the left renal vein where
the lymphatic vessels were coagulated
with bipolar electrodes and ligated with
surgical clips. A total of 23 pelvic lymph
nodes and 27 para-aortic lymph nodes
were obtained; all were reported as being
non-malignant.
 CASE REPORT
• At the time of oral feeding (postoperative day 4), the patient had high-output external
fistula (2000 mL/d) of a white milky fluid through a transabdominal drain.
• A medium-chain triglyceride (MCT) diet and total parenteral nutrition (TPN) was
initiated and was continued for 40 days.
• On postoperative day 43, 100 mg of a somatostatin analog (0.1 mg/mL, octreotide;
Novartis, Basel, Switzerland) was included in the TPN and was administered
subcutaneously 3 times a day, for 10 days.
• After 1 week wherein no abdominal bloating or weight gain was observed, octreotide
administration was interrupted and an oral diet was started.
 CASE REPORT
• Octreotide with TPN was re-administered for an additional 20 days, during which only
one additional paracentesis was performed (Fig. 1).
• We stopped administering the octreotide injections because of the absence of a
detectable increase in bodyweight after substitution of TPN with an MCT diet for a
further 2 days.
• There was no further evidence of ascites over the 14-month follow-up period.
 DISCUSSION –
Chylous Ascites

Para-aortic lymph nodes are exclusively important for the staging of

gynecologic malignancies.

Chylous ascites can develop as a result of leakage from the lymphatic

channels in para-aortic lesions

Recently, the frequency of chylous ascites has increase and the

symptoms have started to develop rapidly as radical surgical procedures

The traditional approaches, which are primarily conservative, include

paracentesis, low-fat diets, and parenteral nutrition

Recommended management strategies based on a step-up approach from

conservative treatment to surgical intervention
 DISCUSSION –
Somatostatin
Somatostatin, or its analog (octreotide), is highly effective in controlling lymphatic flow
 the rapid and strong response in patients refractory to conservative management

The action of somatostatin or inhibit intestinal secretion and

octreotide is mediated through
specific receptors that are
distributed in various regions,
including the pancreas, vascular
tissues and gastrointestinal tract
absorption, resulting in decreased
lymphatic and splanchnic blood
flow, which is also speculated to
be the mechanism involved in
reducing lymphatic production.

reduce lymphatic leakage from

the cisterna chyli through multiple
mechanisms, including reduction
in lymphatic production and direct
contraction of the lymphatic
vessels.
 DISCUSSION –
Somatostatin

• Octreotide, an analog of somatostatin, is effective for the treatment of

postoperative chylous ascites that is refractory to conservative treatment
methods; the inclusion of octreotide therapy should be considered before
proceeding to surgical intervention.

• Considering the increasing incidence of chylous ascites in patients

undergoing surgery for gynecologic cancer

• The use of somatostatin or octreotide should be investigated in further

studies.
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Thank You