Management of Chylous Acid in Gynecological Malignancies

Management of Chylous Acid in Gynecological Malignancies | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Management of Chylous Acid in Gynecological Malignancies Tolga Çiftpınar¹, Ayşe Hazırbulan¹, Nilüfer Çetinkaya Kocadal¹ This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7665070/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Objective: Chylous ascites developing in the abdomen after lymphadenectomy in patients with gynecological malignancies is a rare complication. In this study, we attempted to establish a standard approach for the management of chylous ascites on the basis of our clinical experience. The diagnosis, management, and possible outcomes of chylous ascites were evaluated. Materials and Methods: Between 2020 and 2024, 867 patients who underwent lymphadenectomy for gynecological malignancies at the Gynecological Oncology Clinic of Başakşehir Çam and Sakura City Hospital were retrospectively examined. Results: Chylous ascites (CA) developed in 61 (7%) of 867 patients after surgery. The mean age was 55 years, the body mass index was 31, and the mean hospitalization duration was 10 days. All patients underwent retroperitoneal lymphatic dissection. Paraaortic lymph node dissection was performed in 95.1% of the patients. In 32 of the patients (52.5%) with CA, lymphadenectomy was performed up to the level of the left renal vein. All patients who developed CA were treated with conservative management. A medium-chain triglyceride (MCT) diet was started in all patients. Nine patients (14.8%) started total parenteral nutrition (TPN), and 7 patients (11.5%) used octreotide. Patients with CA had greater drain volumes than those without CA, and patients who started TPN and octreotide had greater drain volumes than those who received only MCT. TPN and octreotide users also had longer hospital stays. Conclusions: The mean drainage volumes on postoperative days 1 and 4 were significantly greater in patients with chylous ascites than in those without chylous ascites (650/450 vs. 830/650). There was a significant, strong, and positive correlation between the amount of drainage on the fourth day and the day that the TPN started according to the Pearson correlation analysis (p=0.009). Biological sciences/Cancer Health sciences/Diseases Health sciences/Gastroenterology Health sciences/Medical research Health sciences/Oncology Chylous ascites gynecological malignancy lymphadenectomy drain volume Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Chylous acid is defined as the pathological accumulation of chylous fluid in the peritoneal cavity following lymphatic leakage (1). It is a rare complication of oncological and retroperitoneal surgery. The incidence of this disease ranges from 1 to 9% for retroperitoneal lymph node dissection and is approximately 7% for oncological abdominal surgery (2). Treatment options include dietary restriction with the addition of medium-chain triglycerides, serial paracentesis, total parenteral nutrition, and somatostatin. The current view is that surgical exploration and peritoneo-venous shunts should be reserved for refractory cases (3). Treatment is easy, and conservative management generally solves this problem. However, if it is not recognized and not managed properly, it can cause severe morbidity. In this study, we evaluated the management and treatment modalities and discussed the possible outcomes of chylous ascites. Materials and Methods Patients who underwent lymphadenectomy for gynecological malignancies at the Gynecological Oncology Clinic of Başakşehir Çam and Sakura City Hospital between June 2020 and April 2024 were evaluated retrospectively. Patients who underwent surgery for a gynecological cancer diagnosis and patients who underwent pelvic or paraaortic lymphadenectomy via laparotomy or laparoscopy were included in the study. Patients who received systemic chemotherapy and/or radiotherapy without primary surgery or patients who underwent surgery but did not undergo lymphadenectomy were excluded from the study. This study was conducted in accordance with the ethical standards of the Helsinki Declaration and Ethics Committee approval, which was received from our hospital’s Clinical Research Ethics Committee with decision number KAEK/ 13.12.2023.648 . Chylous acid is a milky white secretion in the abdominal drain that is routinely used after surgery. Patients who underwent laparoscopy or laparotomy were evaluated separately. The lymphadenectomy level was divided into four levels. They were classified as level 1-pelvic lymphatics, level 2-presacral lymphatics, level 3-inferior to the IMA and level 4-inferior to the renal vein. Data on the onset and treatment of chylous acid and the resolution of symptoms were also collected from patients who developed chylous acid. In patients who developed chylous ascites, postoperative drain volumes were determined. The treatment algorithm for patients was determined on the basis of postoperative drain volumes. Intra-abdominal infections were excluded by repeated C-reactive protein (CRP) and white blood cell count measurements. Surgical and histopathological data were collected for all patients included in the study, including those who underwent pelvic and/or para-aortic lymphadenectomy. Patient demographic data, hospital stay duration, daily drainage amounts, mortality and morbidity rates, treatment modalities, and blood test results were retrospectively collected. Statistical analysis Statistical analysis was performed via IBM SPSS Statistics 24.0. The Kolmogorov‒Smirnov method was used to determine whether the variables were normally distributed. Continuous data [presented as the mean ± SD and median (minimum-maximum)] were analyzed via Student's t test and ANOVA for normally distributed data and via the Mann‒Whitney U test for nonnormally distributed data. ROC curve analysis of categorical variables was performed to determine the most appropriate cutoff value for predicting the chylous phenomenon. All potential risk factors for shilozic acid were then subjected to multivariate analysis via a binary logistic regression model. An evaluation was also performed via Pearson correlation analysis. Kaplan‒Meier analysis was performed for survival assessment. A p value of <0.05 was considered to indicate statistical significance. Results A total of 867 patients underwent systemic pelvic and/or para-aortic lymphadenectomy for gynecological malignancies. In 61 patients (7%), chylous ascites developed. Laparotomy was performed in 95.1% of the patients, and laparoscopy was performed in 4.9%. Pelvic lymph node dissection was performed in 98.4% of patients, and paraaortic lymph node dissection was performed in 96.7%. The average age was 55±14.9 years, and the average body mass index was 31±8.1. Among patients who developed chylous ascites, the indications for surgery were endometrial cancer (36.6%), ovarian cancer (49.2%), and cervical cancer (14.7%). Preoperatively, 72.1% of patients had no ascites, whereas 27.9% had ascites. The average follow-up period for patients was 22 months. The postoperative complication rate was 19.7% (n=12), the mortality rate during follow-up was 13.1% (n=8), and the recurrence rate was 26.2% (n=16). Table 1 shows the demographic and clinical characteristics of the patients. Table 1 Demographic and clinical characteristics Parameter n=61 Number/range % Age 55 BMI 31 Gravida 3 Parity 2 Primary site Cervix 9 %14.7 Ovary 30 %49.2 Endometrium 22 %36.1 Surgery Laparotomy 58 %95.1 Laparoscopy 3 %4.9 Operation TLH BSO PPLND 3 Debulking Surgery 49 Radical Hysterectomy PPLND 9 Lymphadenectomy Pelvic 60 %98.4 Paraaortic 59 %96.7 Lymph node collected Paraaortic 16 Total 40 Lymph Node status Pelvic + 13 %21.3 Paraaortic + 14 %22.9 Pre op ascites status Pre op ascites ( +) 44 %72.1 Pre op ascites ( -) 17 %27.9 Follow-up (months) 22 Complication 12 %19.7 Mortality 8 %13.1 Recurrence 16 %26.2 Postoperatively, chylous ascites developed on average on the 3rd day. The drains of patients who developed chylous ascites were removed on average on the 6th day. The average length of hospital stay was 10 days. A chyle diet that includes high-protein, low-fat, medium-chain triglyceride (MCT) was started in all patients who developed chylous ascites. Total parenteral nutrition (TPN) was started in 9 (14.8%) patients who did not improve. TPN was started on an average of the 6th day and was administered for 3 days. Octreotide was initiated in 7 (11.5%) patients on the 6th day and was administered for an average of 5 days. The average length of hospital stay was 13 days for the TPN group and 14 days for the octreotide group. Figure 1 shows the characteristics of conservative management, MCT, TPN, and octreotide use in patients. The amount of drainage on the first postoperative day was greater in patients who underwent laparotomy than in those who underwent laparoscopy. The median drain volume on the first postoperative day was 470 cc (min–max; 25--1700) in patients who underwent laparotomy and 110 cc (min–max; 100--125; p=0.047) in patients who underwent laparoscopy. The drainage volume on the first postoperative day was greater in patients with intra-abdominal fluid. The median drainage volume on the first postoperative day was 500 cc in patients with ascites before surgery and 350 cc in patients without ascites before surgery (p value 0.031). There was no significant difference in drainage volume between patients who had positive pelvic lymph nodes and those who did not. Postoperative drainage volumes were similar, although slightly greater, in patients with positive lymph nodes. There was a significant difference between the lymph node level and the amount of drainage. When analyzed via the Bonferroni correction, there was a significant difference in the drainage amount between the infra-aortic lymph node (Level 2) (400 cc, min–max; 50--1200) dissection and the supra-aortic lymph node (Level 3) (870 cc, min–max; 300--2200) dissection (p value 0.013, rank mean 7.39--14.35, respectively). When para-aortic lymph node dissection up to the level of the left renal vein (Level 4) (550 cc, min–max; 100–1150) was compared with Level 2 and Level 3 para-aortic lymph node dissection, there was no significant difference. Lympadenectomy of the superior IMA was related to a greater drain volume. In patients with chylous ascites, lymph node dissection levels had similar mortality curves, and there was no significant correlation between them (p = 0.4) (Figure 2). Level 2, 3, and 4 lymph node dissections performed in patients with chylous ascites did not affect overall survival. Daily drainage volumes were also found not to affect overall survival or disease-free survival in patients with chylous ascites (Figure 3). The patients who underwent TPN had longer hospitalizations, greater drain volumes on the 1st postoperative day, and longer removal times. The patients had 13 days of hospitalization, while the average hospitalization time was 10 days (p=0.01). The average drain volume was 450 cc (min–max: 25--1700), and the average drain removal time was 10, while the average drain volume was 0.042 and 0.001 on the 5th postoperative day. Pearson correlation analysis revealed a significant, strong, positive correlation between the amount of drainage performed on the fourth postoperative day and the day that TPN was initiated (p = 0.009). The average drainage volume on the 4th postoperative day for patients who started TPN was 830 cc (min–max; 350--1800). This value was greater than the average postoperative drainage volume (650 cc.) of the 4th day. There was a significant, strong, and positive correlation between the number of days TPN was administered and the number of days octreotide was administered (p = 0.025). When the number of days that TPN was administered to patients increased, the number of days that octreotide was administered also increased. There was a significant correlation between octreotide use and drainage volume on postoperative day 3 (p=0.016, beta coefficient = 0.003). The average drainage volume on postoperative day 3 was 680 cc, and patients who started octreotide treatment had greater drainage volumes. The patients given octreotide had longer hospitalizations, greater drain volumes on the 3rd and 6th postoperative days, and longer drain removal times. The patients had 14 days of hospitalization, while the average hospitalization time was 10 days (p=0.001). The average drain volume was 900 cc (min–max; 520--2200) on the 3rd postoperative day and 800 cc (min–max; 350--2200) on the 6th postoperative day, while the average drain volumes were 680 cc (min–max: 25--1600) and 550 cc (min–max: 50--1000), with p values of 0.041 and 0.028, respectively. The average duration of drain removal was 10 days for patients given octreotide (min–max; 7–17, SD; 3,54, p=0.003). Table 2 contains the drain parameters. The algorithm for monitoring drain output on postoperative days 1, 3, 4, and 6 is shown in Figure 4. Table 2 Drainage parameters CA n=61 MCT n=52 TPN n=9 Octreotide n=7 P value Drain volume (cc.) Drain vol day 1 450 410 650 650 p=0.04 Drain vol day 3 680 650 850 900 p=0.01 Drain vol day 4 650 600 830 830 p=0.009 Drain vol day 6 550 430 730 800 p=0.02 Postoperative globulin and total protein values were lower in patients who started Octreotide than in patients who did not receive Octreotide. In patients receiving octreotide, the mean postoperative globulin value was 19 (min–max; 13–23, p=0.048), and the mean postoperative total protein value was 47 (min–max; 48–52, p=0.049). There was a significant, very strong inverse relationship between the number of days octreotide was administered and postoperative globulin levels (p=0.015). The average postoperative blood globulin value of patients given octreotide was 19. As blood globulin levels decreased, an increase in the number of days octreotide was administered. There was a significant, moderately strong inverse relationship between the amount of drainage on the fourth postoperative day and the postoperative globulin level (p=0.019). The average postoperative globulin value was 22, and the average drainage volume on the fourth postoperative day was 650 cc. As the amount of globulin decreased, an increase in the amount of drainage fluid was observed. The ROC analysis revealed no significant correlation between patient drain volume and patient drain volume. Intraoperative and postoperative complications developed in 12 (19.7%) patients. These included subileus, sinus tachycardia, atelectasis, trocar site intestinal herniation, ureter injury, lymphedema, wound dehiscence, wound site infection, intra-abdominal abscess, lymphocele, thrombocytopenia, and pulmonary embolism. The patients who experienced postoperative complications were discharged later (on the 16th PO) than the other patients were (p=0.004). Additionally, patients who died had longer hospital stays (PO 13th day, p=0.033) and higher BMIs (36.69-min–max; 20.75-48.80, p=0.033). Discussion In gynecological oncology, retroperitoneal lymphadenectomy is the major operative technique for most cases. Interventions targeting this lymphatic pathway may lead to iatrogenic defects resulting in persistent accumulation of chylous fluid in the abdominal cavity. The incidence varies according to the studies and the surgeries performed. Among gynecologic malignancies, 0.17 to 9% (4,5) and 20.8% among testicular cancer surgeries constitute the highest percentage after surgery (6). This rare but noteworthy condition may cause anxiety in both patients and surgeons because of its typical milky appearance. It may cause malnutrition, dehydration and loss of protein due to volume depletion. The prolongation of this complication increases surgical morbidity and delays recovery and adjuvant therapy for malignancy (2). The main pathophysiologic mechanism is dysfunction of the lymphatic circulation. This may be due to retroperitoneal dissection without ligation of the lymphatic vessels or swelling and rupturing of the vessels by blocking the lymphatic circulation. It also causes stasis, inflammation, vessel edema and lymphatic leakage by increasing permeability (7). In this study, chylous ascites developed in 7% of the patients. This ratio is high but similar to that reported in the literature. This is probably because of extensive surgery of the lymphatic region. The reason may be that the end part of the lymphatics was not ligated. If we do not observe suspicious damage or leakage from the vessels, we generally do not use hemoclips at the end of the lymphatic pathway. The possible reasons for chylous ascites are the operative technique (laparoscopy, laparotomy or robotic surgery), the number of removed lymph nodes, the level of the lymphadenectomy region, the use of drainage tubes, and the use of electrosurgery for dissection. Even the malignant disease itself may cause an obstruction of the lymphatics, and these dilated lymphatics may lead to exudation and leakage of chylous ascites because of rupture (8). The majority of our patients developed chylous ascites after laparotomy (95.1%), with a much smaller proportion following laparoscopic lymphadenectomy (4.9%). Data comparing the type of surgery used in gynecological surgeries regarding the development of chylous ascites are quite limited in the literature. In a study by Zhao (9), which evaluated only those who underwent laparoscopy, the incidence of chylous ascites (CA) was found to be 0.9% among laparoscopy (L/S) patients. In a study by Thiel (10) that compared L/S and laparotomy (L/T), the development of CA in L/S patients was significantly different from that in L/T patients (14.3% vs. 1.9%). They explained the higher incidence of CA in laparoscopy by harvesting techniques, lymphatic vessel sealing, differences in intra-abdominal pressure, and differences in the accessibility of particular lymph node regions rather than the number of lymph nodes removed. A recent study (11) comparing robotic, laparoscopic, and laparotomic techniques in patients with rectal cancer in terms of operative methods reported a higher incidence of CA in patients who underwent minimally invasive surgery, especially robotic surgery, than in those who underwent open surgery. This higher incidence in robotic surgery was attributed to the inadequacy of the ultrasonic knife in coagulation and the lack of tactile sensation in the robot, which leads to uncontrolled tissue traction and lymphatic damage. Similarly, the uncontrolled use of force in laparoscopy may be related to the increased risk of lymphatic vessel damage. The number of lymph nodes collected and the extent of lymphadenectomy are among the most important factors in the development of chylous ascites. Thiel et al. (10) reported that chylous ascites was more common in patients whose number of collected lymph nodes was greater (51--40) than in those whose number of collected lymph nodes was lower. Tulunay's (12) study revealed that having more than 14 paraaortic lymph nodes was associated with chylous ascites. In our study, the mean total lymph node count in patients who developed chylous ascites was 40, and the median paraaortic lymph node count was 16, which is similar to the literature. Coagulation of major lymphatic vessels by ultrasonically activated shears can cause terminal injury to surrounding tissues or even central lymphatics. during laparoscopic lymphadenectomy, whereas suture ligation of major lymphatic vessels can prevent damage in laparotomic lymph node dissection (9). The level of dissection also affects the degree of lymphatic damage. Compared with dissection of the pelvic lymph nodes, the region from the bifurcation of the aorta to the renal veins is more likely to damage the central lymphatics. The size of the node and terminal injury to the surrounding tissues or central lymphatics may be responsible for postoperative CA (13). Ligation of the roots of the lymphatic channels via hemoclips can prevent lymphatic damage and chylous leakage. Malignant tumors may cause CA through lymphatic disruption, direct invasion, or extrinsic compression, all of which lead to obstruction. This condition is more common in lymphomas and is also observed in some ovarian tumors, pancreas cancer, colon cancer and kidney cancer (8). In this study, we observed a greater drain volume in patients who underwent level 3 dissection than in those who underwent level 2 dissection. No difference was observed between levels 2 and 3 compared with level 4, but since level 3 was already higher, we can predict that lymphadenectomy superior to the inferior mesenteric artery is associated with a greater drain volume. Conservative management is the first choice in the treatment of CA. A high-protein, low-fat, medium-chain triglyceride (MCT)-based diet, diuretics (spironolactone), total parenteral nutrition (TPN) and somatostatins may be used. They decrease the intestinal absorption of fats and gastrointestinal secretions and attenuate total lymph flow. Paracentesis, lymphangiography and surgery must be performed for refractory cases (14). Conservative management is usually the initial therapeutic option, and it has high success rates (71–100%) (15). Early drain removal can lead to asymptomatic patients being overlooked. Drain removal timing is determined by the daily drainage volume, which generally occurs when the daily drainage volume falls below 50 cc or 100 cc. In our clinical routine, we remove drains when the daily drainage volume falls below 100 cc. In CA, the drainage volume increases, and milky fluid begins to be observed. This increased daily drain volume in the postoperative period can guide the management of chylous ascites. In our study, the mean drain volume in patients with CA on days 1 and 4 was significantly greater than that in patients without CA (650/450 vs. 830/650). Concurrently, the drain volume in patients who underwent TPN on day 4 exceeded 830 cc. This value was greater than the average postoperative drainage volume (600 cc.) of the 4th day. Pearson correlation analysis revealed a significant, strong, positive correlation between the amount of drainage performed on the fourth postoperative day and the day that TPN was initiated (p=0.009). There was a similar positive correlation between the number of days TPN was administered and the number of days octreotide was administered (p=0.025). For patients resistant to the chylous diet, both TPN and octreotide therapy were administered concurrently to facilitate faster recovery. Chylous ascites appeared on the 3rd day, and if the chylous diet was consumed, the drains were removed approximately on the 6th day. In the resistant group, the drains were removed on the 10th day of TPN and octreotide treatment. In other words, CA development was observed in patients whose drains were above 670 on day 4, and TPN use was observed in patients whose drains were above 830 cc. On day 4. In TPN users, octreotide use was observed to increase at the same time. Chylous ascites onset, the time to treatment, and recovery times for those using diet and TPN vary significantly among studies since the data of the studies depend on low case numbers or case reports. The time to onset of chylous ascites can range from 4--30 days, and recovery can range from 7--44 days in Solmaz’s study (5). Tan et al. (13) summarized the treatment management of 140 patients in a review of 16 studies. Accordingly, the time to onset of chylous ascites and resolution was 5–9 days for L/T and 3.5–8 days for L/S. Among the patients treated conservatively, 27% were treated with MCT, 52% with TPN, and 9% with TPN + MCT. The resolution was 12 days for MCT, 9 days for TPN, and 18 days for TPN + MCT. In our study, the onset of chylous ascites was 3 days, and the average resolution was 6 days. The resolution for MCT was 5 days, that for TPN was 9 days, and that for octreotide was 10 days. A total of 14.8% of the patients received TPN alone, and 11.5% of the patients received both TPN and octreotide. The remaining patients received only an MCT diet and recovered. In this study, those receiving octreotide treatment had lower globulin (p=0.048) and total protein levels (p=0.049). The same inverse relationship was also observed with the duration of octreotide administration (p=0.015). As globulin levels decreased, the duration of octreotide use increased. While albumin is a protein that is also lost in chylous ascites, it may be influenced by many factors and regulated by hepatic synthesis. However, the loss of immunoglobulins, which are a fraction of globulins produced by lymphatic leakage, may be associated with chylous ascites and increased octreotide requirements and may correlate with lymphatic leakage. Globulin levels may reflect losses in chylous ascites. Finally, uncomplicated and treated CA does not affect survival or mortality. We found no correlation between CA and mortality. No correlation was found between different levels of lymphadenectomy, drainage volumes, or survival. Conclusions In the patients included in the study, postoperative drainage, total parenteral nutrition, octreotide, and dietary intervention were successfully managed. Postoperative chylous ascites is a rare complication of retroperitoneal surgery resulting from accidental disruption of major retroperitoneal lymphatics and may be associated with serious mechanical, nutritional, and immunological consequences due to the continuous loss of protein and lymphocytes. Various treatment regimens can be used successfully to treat chylous ascites. There is no standard management for chylous ascites after lymphadenectomy because there is little evidence from case series or expert opinion. Initially, medical and conservative treatment is recommended. In resistant patients, interventional management or surgical treatment may be recommended. The prognosis for patients with chylous ascites is generally good, and most patients respond to conservative measures. An individualized approach with multidisciplinary participation should always be taken. However, the best policy is to prevent chylous complications by carefully controlling the major lymphatics via meticulous dissection techniques and suture ligation during primary surgical intervention. Declarations Acknowledgements Not applicable. Author information Başakşehir Çam and Sakura City Hospital, Department of Gynecologic Oncology Surgery, Istanbul, Türkiye Tolga Çiftpınar Başakşehir Çam and Sakura City Hospital, Department of Gynecologic Oncology Surgery, Istanbul, Türkiye Ayşe Hazırbulan Başakşehir Çam and Sakura City Hospital, Department of Gynecologic Oncology Surgery, Istanbul, Türkiye Nilüfer Çetinkaya Kocadal Corresponding author: Tolga Çiftpınar e-mail: [email protected] Ethics approval and consent to participate The study was carried out by the Declaration of Helsinki, and the study protocol was approved by the hospital’s Local Ethics Committee with the acceptance number 13.12.2023.648. The participants were informed about the study objectives and methods, assured of data confidentiality, and provided written informed consent prior to participation. Clinical trial number Not applicable. Funding No grant funding was utilized to conduct the research outlined in this document. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7665070","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":580010179,"identity":"ea712917-b89f-42fc-bca9-511f42dba052","order_by":0,"name":"Tolga Çiftpınar¹","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+0lEQVRIiWNgGAWjYFAC5gYgIcHPwMAIYtgA2QQ08EBUSkj2QBhpRGthAGoBg8OEtdizNza/+FFjIWEv3dz24Oee84n9s5sPPmCosYnGaQvPwTbLnmMSEjwyB9sNe57dTpxx51iyAcOxtNwGXFokEtsMeBsk6kAMCZ4DtxMbbuSYSTA2HMarxfBvA9AWIEPyz4FzifOJ0NL8mBeqRZrnwIHEDQS1nDnYxiwD8sudg23SMgeSjTfeSEs2SMDjF/b25sMf39TUSbDPbn8m+eaAney8G8kHH3yoscGpBQjYIBEBjQ5HsMoE3MpBgPkDshZ7/IpHwSgYBaNgJAIAQVRchfEIg0YAAAAASUVORK5CYII=","orcid":"","institution":"¹Başakşehir Çam and Sakura City Hospital","correspondingAuthor":true,"prefix":"","firstName":"Tolga","middleName":"","lastName":"Çiftpınar¹","suffix":""},{"id":580010180,"identity":"311f03da-6b4f-4f49-a487-18e66c305a01","order_by":1,"name":"Ayşe Hazırbulan¹","email":"","orcid":"","institution":"¹Başakşehir Çam and Sakura City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ayşe","middleName":"","lastName":"Hazırbulan¹","suffix":""},{"id":580010181,"identity":"43e585f8-197a-4d73-8301-06e9a8af8fb0","order_by":2,"name":"Nilüfer Çetinkaya Kocadal¹","email":"","orcid":"","institution":"¹Başakşehir Çam and Sakura City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Nilüfer","middleName":"Çetinkaya","lastName":"Kocadal¹","suffix":""}],"badges":[],"createdAt":"2025-09-20 15:23:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7665070/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7665070/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101274450,"identity":"7f6f0919-55df-4ba8-932c-989cabfe56e9","added_by":"auto","created_at":"2026-01-28 03:10:31","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":49825,"visible":true,"origin":"","legend":"\u003cp\u003eCharacteristics of conservative management\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7665070/v1/5e28ed02a6802b5d6b5ad1a0.png"},{"id":101274486,"identity":"3c4ae329-3ce8-41e4-a720-f91799f1ab65","added_by":"auto","created_at":"2026-01-28 03:10:43","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":21207,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRelationships between the number of dissected lymph nodes and overall survival\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7665070/v1/eed569c2aababc25d8638f4d.png"},{"id":101274432,"identity":"140a74d6-edcf-4279-929d-f6f0d0636069","added_by":"auto","created_at":"2026-01-28 03:10:25","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":20989,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRelationships between the degree of lymph node dissection and disease-free survival\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7665070/v1/efab5e9e5acb2d108fe16f09.png"},{"id":101274444,"identity":"da0dcb25-cebe-49f9-a5c0-b5db01b7764e","added_by":"auto","created_at":"2026-01-28 03:10:28","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":52145,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTreatment flowchart and drainage volumes on days 1, 3, 4, and 6 after surgery.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7665070/v1/b86b5e8d490210a7bbda7cec.png"},{"id":101274516,"identity":"268698bb-4b54-4f4f-aa24-c5165edebdcc","added_by":"auto","created_at":"2026-01-28 03:10:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":938846,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7665070/v1/5c24dfbc-5b6d-420c-b020-79f49c9fbc54.pdf"},{"id":101274440,"identity":"7f8a0e4a-c1f1-4edb-9893-2e2182b6c079","added_by":"auto","created_at":"2026-01-28 03:10:26","extension":"xls","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":53248,"visible":true,"origin":"","legend":"","description":"","filename":"LZDATA.xls","url":"https://assets-eu.researchsquare.com/files/rs-7665070/v1/d0898710bfa0ad0dbbeae9f1.xls"}],"financialInterests":"No competing interests reported.","formattedTitle":"Management of Chylous Acid in Gynecological Malignancies","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChylous acid is defined as the pathological accumulation of chylous fluid in the peritoneal cavity following lymphatic leakage (1). It is a rare complication of oncological and retroperitoneal surgery. The incidence of this disease ranges from 1 to 9% for retroperitoneal lymph node dissection and is approximately 7% for oncological abdominal surgery (2). Treatment options include dietary restriction with the addition of medium-chain triglycerides, serial paracentesis, total parenteral nutrition, and somatostatin. The current view is that surgical exploration and peritoneo-venous shunts should be reserved for refractory cases (3). Treatment is easy, and conservative management generally solves this problem. However, if it is not recognized and not managed properly, it can cause severe morbidity. In this study, we evaluated the management and treatment modalities and discussed the possible outcomes of chylous ascites.\u003c/p\u003e\n"},{"header":"Materials and Methods","content":"\u003cp\u003ePatients who underwent lymphadenectomy for gynecological malignancies at the Gynecological Oncology Clinic of Başakşehir \u0026Ccedil;am and Sakura City Hospital between June 2020 and April 2024 were evaluated retrospectively.\u0026nbsp;Patients who underwent surgery for a gynecological cancer diagnosis and patients who underwent pelvic or paraaortic lymphadenectomy via laparotomy or laparoscopy were included in the study.\u0026nbsp;Patients who received systemic chemotherapy and/or radiotherapy without primary surgery or patients who underwent surgery but did not undergo lymphadenectomy were excluded from the study. This study was conducted in accordance with the ethical standards of the Helsinki Declaration and\u0026nbsp;Ethics Committee approval, which was received from our hospital\u0026rsquo;s Clinical Research Ethics Committee with decision number\u003cstrong\u003e\u0026nbsp;KAEK/\u003c/strong\u003e\u003cstrong\u003e13.12.2023.648\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eChylous acid is a milky white secretion in the abdominal drain that is routinely used after surgery. Patients who underwent laparoscopy or laparotomy were evaluated separately. The lymphadenectomy level was divided into four levels. They were classified as level 1-pelvic lymphatics, level 2-presacral lymphatics, level 3-inferior to the IMA and level 4-inferior to the renal vein. Data on the onset and treatment of chylous acid and the resolution of symptoms were also collected from patients who developed chylous acid. In patients who developed chylous ascites, postoperative drain volumes were determined. The treatment algorithm for patients was determined on the basis of postoperative drain volumes. Intra-abdominal infections were excluded by repeated C-reactive protein (CRP) and white blood cell count measurements. Surgical and histopathological data were collected for all patients included in the study, including those who underwent pelvic and/or para-aortic lymphadenectomy. Patient demographic data, hospital stay duration, daily drainage amounts, mortality and morbidity rates, treatment modalities, and blood test results were retrospectively collected.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e Statistical analysis was performed via IBM SPSS Statistics 24.0. The Kolmogorov‒Smirnov method was used to determine whether the variables were normally distributed. Continuous data [presented as the mean \u0026plusmn; SD and median (minimum-maximum)] were analyzed via Student\u0026apos;s t test and ANOVA for normally distributed data and via the Mann‒Whitney U test for nonnormally distributed data. ROC curve analysis of categorical variables was performed to determine the most appropriate cutoff value for predicting the chylous phenomenon. All potential risk factors for shilozic acid were then subjected to multivariate analysis via a binary logistic regression model. An evaluation was also performed via Pearson correlation analysis. Kaplan‒Meier analysis was performed for survival assessment. A p value of \u0026lt;0.05 was considered to indicate statistical significance.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 867 patients underwent systemic pelvic and/or para-aortic lymphadenectomy for gynecological malignancies. In 61 patients (7%), chylous ascites developed. Laparotomy was performed in 95.1% of the patients, and laparoscopy was performed in 4.9%. Pelvic lymph node dissection was performed in 98.4% of patients, and paraaortic lymph node dissection was performed in 96.7%. The average age was 55\u0026plusmn;14.9 years, and the average body mass index was 31\u0026plusmn;8.1. Among patients who developed chylous ascites, the indications for surgery were endometrial cancer (36.6%), ovarian cancer (49.2%), and cervical cancer (14.7%). Preoperatively, 72.1% of patients had no ascites, whereas 27.9% had ascites. The average follow-up period for patients was 22 months. The postoperative complication rate was 19.7% (n=12), the mortality rate during follow-up was 13.1% (n=8), and the recurrence rate was 26.2% (n=16). Table 1 shows the demographic and clinical characteristics of the patients.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1 Demographic and clinical characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter n=61\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber/range\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGravida\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary site\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eCervix\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e%14.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eOvary\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e%49.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eEndometrium\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e%36.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eLaparotomy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e%95.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eLaparoscopy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e%4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOperation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eTLH BSO PPLND\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eDebulking Surgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eRadical Hysterectomy PPLND\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLymphadenectomy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ePelvic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e%98.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eParaaortic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e%96.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLymph node collected\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eParaaortic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLymph Node status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ePelvic +\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e%21.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eParaaortic +\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e%22.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre op ascites status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ePre op ascites (\u003c/strong\u003e\u003cstrong\u003e+)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e%72.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ePre op ascites (\u003c/strong\u003e\u003cstrong\u003e-)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e%27.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFollow-up (months)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eComplication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e%19.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eMortality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e%13.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eRecurrence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e%26.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePostoperatively, chylous ascites developed on average on the 3rd day. The drains of patients who developed chylous ascites were removed on average on the 6th day. The average length of hospital stay was 10 days. A chyle diet that includes high-protein, low-fat, medium-chain triglyceride (MCT) was started in all patients who developed chylous ascites. Total parenteral nutrition (TPN) was started in 9 (14.8%) patients who did not improve. TPN was started on an average of the 6th day and was administered for 3 days. Octreotide was initiated in 7 (11.5%) patients on the 6th day and was administered for an average of 5 days. The average length of hospital stay was 13 days for the TPN group and 14 days for the octreotide group. Figure 1 shows the characteristics of conservative management, MCT, TPN, and octreotide use in patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe amount of drainage on the first postoperative day was greater in patients who underwent laparotomy than in those who underwent laparoscopy. The median drain volume on the first postoperative day was 470 cc (min\u0026ndash;max; 25--1700) in patients who underwent laparotomy and 110 cc (min\u0026ndash;max; 100--125; p=0.047) in patients who underwent laparoscopy. The drainage volume on the first postoperative day was greater in patients with intra-abdominal fluid. The median drainage volume on the first postoperative day was 500 cc in patients with ascites before surgery and 350 cc in patients without ascites before surgery (p value 0.031).\u003c/p\u003e\n\u003cp\u003eThere was no significant difference in drainage volume between patients who had positive pelvic lymph nodes and those who did not. Postoperative drainage volumes were similar, although slightly greater, in patients with positive lymph nodes.\u0026nbsp;There was a significant difference between the lymph node level and the amount of drainage. When analyzed via the Bonferroni correction, there was a significant difference in the drainage amount between the infra-aortic lymph node (Level 2) (400 cc, min\u0026ndash;max; 50--1200) dissection and the supra-aortic lymph node (Level 3) (870 cc, min\u0026ndash;max; 300--2200) dissection (p value 0.013, rank mean 7.39--14.35, respectively). When para-aortic lymph node dissection up to the level of the left renal vein (Level 4) (550 cc, min\u0026ndash;max; 100\u0026ndash;1150) was compared with Level 2 and Level 3 para-aortic lymph node dissection, there was no significant difference. Lympadenectomy of the superior IMA was related to a greater drain volume.\u003c/p\u003e\n\u003cp\u003eIn patients with chylous ascites, lymph node dissection levels had similar mortality curves, and there was no significant correlation between them (p = 0.4) \u003cstrong\u003e(Figure 2).\u003c/strong\u003e Level 2, 3, and 4 lymph node dissections performed in patients with chylous ascites did not affect overall survival. Daily drainage volumes were also found not to affect overall survival or disease-free survival in patients with chylous ascites \u003cstrong\u003e(Figure 3).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patients who underwent TPN had longer hospitalizations, greater drain volumes on the 1st postoperative day, and longer removal times. The patients had 13 days of hospitalization, while the average hospitalization time was 10 days (p=0.01). The average drain volume was 450 cc (min\u0026ndash;max: 25--1700), and the average drain removal time was 10, while the average drain volume was 0.042 and 0.001 on the 5th postoperative day. Pearson correlation analysis revealed a significant, strong, positive correlation between the amount of drainage performed on the fourth postoperative day and the day that TPN was initiated (p = 0.009). The average drainage volume on the 4th postoperative day for patients who started TPN was 830 cc (min\u0026ndash;max; 350--1800). This value was greater than the average postoperative drainage volume (650 cc.) of the 4th day. There was a significant, strong, and positive correlation between the number of days TPN was administered and the number of days octreotide was administered (p = 0.025). When the number of days that TPN was administered to patients increased, the number of days that octreotide was administered also increased.\u003c/p\u003e\n\u003cp\u003eThere was a significant correlation between octreotide use and drainage volume on postoperative day 3 (p=0.016, beta coefficient = 0.003). The average drainage volume on postoperative day 3 was 680 cc, and patients who started octreotide treatment had greater drainage volumes. The patients given octreotide had longer hospitalizations, greater drain volumes on the 3rd and 6th postoperative days, and longer drain removal times. The patients had 14 days of hospitalization, while the average hospitalization time was 10 days (p=0.001). The average drain volume was 900 cc (min\u0026ndash;max; 520--2200) on the 3rd postoperative day and 800 cc (min\u0026ndash;max; 350--2200) on the 6th postoperative day, while the average drain volumes were 680 cc (min\u0026ndash;max: 25--1600) and 550 cc (min\u0026ndash;max: 50--1000), with p values of 0.041 and 0.028, respectively. The average duration of drain removal was 10 days for patients given octreotide (min\u0026ndash;max; 7\u0026ndash;17, SD; 3,54, p=0.003). Table 2 contains the drain parameters. The algorithm for monitoring drain output on postoperative days 1, 3, 4, and 6 is shown in Figure 4.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2 Drainage parameters\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCA\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=61\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMCT\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=52\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTPN\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOctreotide\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDrain volume (cc.)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eDrain vol day 1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e450\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e410\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e650\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e650\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003ep=0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eDrain vol day 3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e680\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e650\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e850\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e900\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003ep=0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eDrain vol day 4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e650\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e600\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e830\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e830\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003ep=0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 192px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eDrain vol day 6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e550\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e430\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e730\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 110px;\"\u003e\n \u003cp\u003e800\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003ep=0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ePostoperative globulin and total protein values were lower in patients who started Octreotide than in patients who did not receive Octreotide. In patients receiving octreotide, the mean postoperative globulin value was 19 (min\u0026ndash;max; 13\u0026ndash;23, p=0.048), and the mean postoperative total protein value was 47 (min\u0026ndash;max; 48\u0026ndash;52, p=0.049). There was a significant, very strong inverse relationship between the number of days octreotide was administered and postoperative globulin levels (p=0.015). The average postoperative blood globulin value of patients given octreotide was 19. As blood globulin levels decreased, an increase in the number of days octreotide was administered. There was a significant, moderately strong inverse relationship between the amount of drainage on the fourth postoperative day and the postoperative globulin level (p=0.019). The average postoperative globulin value was 22, and the average drainage volume on the fourth postoperative day was 650 cc. As the amount of globulin decreased, an increase in the amount of drainage fluid was observed.\u003c/p\u003e\n\u003cp\u003eThe ROC analysis revealed no significant correlation between patient drain volume and patient drain volume. Intraoperative and postoperative complications developed in 12 (19.7%) patients. These included subileus, sinus tachycardia, atelectasis, trocar site intestinal herniation, ureter injury, lymphedema, wound dehiscence, wound site infection, intra-abdominal abscess, lymphocele, thrombocytopenia, and pulmonary embolism. The patients who experienced postoperative complications were discharged later (on the 16th PO) than the other patients were (p=0.004). Additionally, patients who died had longer hospital stays (PO 13th day, p=0.033) and higher BMIs (36.69-min\u0026ndash;max; 20.75-48.80, p=0.033).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn gynecological oncology, retroperitoneal lymphadenectomy is the major operative technique for most cases. Interventions targeting this lymphatic pathway may lead to iatrogenic defects resulting in persistent accumulation of chylous fluid in the abdominal cavity. The incidence varies according to the studies and the surgeries performed. Among gynecologic malignancies, 0.17 to 9% (4,5) and 20.8% among testicular cancer surgeries constitute the highest percentage after surgery (6). This rare but noteworthy condition may cause anxiety in both patients and surgeons because of its typical milky appearance. It may cause malnutrition, dehydration and loss of protein due to volume depletion. The prolongation of this complication increases surgical morbidity and delays recovery and adjuvant therapy for malignancy (2). The main pathophysiologic mechanism is dysfunction of the lymphatic circulation. This may be due to retroperitoneal dissection without ligation of the lymphatic vessels or swelling and rupturing of the vessels by blocking the lymphatic circulation. It also causes stasis, inflammation, vessel edema and lymphatic leakage by increasing permeability (7). In this study, chylous ascites developed in 7% of the patients. This ratio is high but similar to that reported in the literature. This is probably because of extensive surgery of the lymphatic region. The reason may be that the end part of the lymphatics was not ligated. If we do not observe suspicious damage or leakage from the vessels, we generally do not use hemoclips at the end of the lymphatic pathway.\u003c/p\u003e\n\u003cp\u003eThe possible reasons for chylous ascites are the operative technique (laparoscopy, laparotomy or robotic surgery), the number of removed lymph nodes, the level of the lymphadenectomy region, the use of drainage tubes, and the use of electrosurgery for dissection. Even the malignant disease itself may cause an obstruction of the lymphatics, and these dilated lymphatics may lead to exudation and leakage of chylous ascites because of rupture (8).\u003c/p\u003e\n\u003cp\u003eThe majority of\u0026nbsp;our patients developed chylous ascites after laparotomy (95.1%), with a much smaller proportion following laparoscopic lymphadenectomy (4.9%). Data comparing the type of surgery used in gynecological surgeries regarding the development of chylous ascites are quite limited in the literature. In a study by Zhao (9), which evaluated only those who underwent laparoscopy, the incidence of chylous ascites (CA) was found to be 0.9% among laparoscopy (L/S) patients. In a study by Thiel (10) that compared L/S and laparotomy (L/T), the development of CA in L/S patients was significantly different from that in L/T patients (14.3% vs. 1.9%). They explained the higher incidence of CA in laparoscopy by harvesting techniques, lymphatic vessel sealing, differences in intra-abdominal pressure, and differences in the accessibility of particular lymph node regions rather than the number of lymph nodes removed. A recent study (11) comparing robotic, laparoscopic, and laparotomic techniques in patients with rectal cancer in terms of operative methods reported a higher incidence of CA in patients who underwent minimally invasive surgery, especially robotic surgery, than in those who underwent open\u0026nbsp;surgery. This higher incidence in robotic surgery was attributed to the inadequacy of the ultrasonic knife in coagulation and the lack of tactile sensation in the robot, which leads to uncontrolled tissue traction and lymphatic damage. Similarly, the uncontrolled use of force in laparoscopy may be related to the increased risk of lymphatic vessel damage.\u003c/p\u003e\n\u003cp\u003eThe number of lymph nodes collected and the extent of lymphadenectomy are among the most important factors in the development of chylous ascites. Thiel et al. (10) reported that chylous ascites was more common in patients whose number of collected lymph nodes was greater (51--40) than in those whose number of collected lymph nodes was lower. Tulunay's (12) study revealed that having more than 14 paraaortic lymph nodes was associated with chylous ascites. In our study, the mean total lymph node count in patients who developed chylous ascites was 40, and the median paraaortic lymph node count was 16, which is similar to the literature.\u003c/p\u003e\n\u003cp\u003eCoagulation of major lymphatic vessels by ultrasonically activated shears can cause terminal injury to surrounding tissues or even central lymphatics. during laparoscopic lymphadenectomy, whereas suture ligation of major lymphatic vessels can prevent damage in laparotomic lymph node dissection (9). The level of dissection also affects the degree of lymphatic damage. Compared with dissection of the pelvic lymph nodes, the region from the bifurcation of the aorta to the renal veins is more likely to damage the central lymphatics. The size of the node and terminal injury to the surrounding tissues or central lymphatics may be responsible for postoperative CA\u0026nbsp;(13). Ligation of the roots of the lymphatic channels via hemoclips can prevent lymphatic damage and chylous leakage. Malignant tumors may cause CA through lymphatic disruption, direct invasion, or extrinsic compression, all of which lead to obstruction. This condition is more common in lymphomas and is also observed in some ovarian tumors, pancreas cancer, colon cancer and kidney cancer (8).\u0026nbsp;In this study, we observed a greater drain volume in patients who underwent level 3 dissection than in those who underwent level 2 dissection. No difference was observed between levels 2 and 3 compared with level 4, but since level 3 was already higher, we can predict that lymphadenectomy superior to the inferior mesenteric artery is associated with a greater drain volume.\u003c/p\u003e\n\u003cp\u003eConservative management is the first choice in the treatment of CA. A high-protein, low-fat, medium-chain triglyceride (MCT)-based diet, diuretics (spironolactone), total parenteral nutrition (TPN) and somatostatins may be used. They decrease the intestinal absorption of fats and gastrointestinal secretions and attenuate total lymph flow. Paracentesis, lymphangiography and surgery must be performed for refractory cases (14). Conservative management is usually the initial therapeutic option, and it has high success rates (71–100%) (15).\u003c/p\u003e\n\u003cp\u003eEarly drain removal can lead to asymptomatic patients being overlooked. Drain removal timing is determined by the daily drainage volume, which generally occurs when the daily drainage volume falls below 50 cc or 100 cc. In our clinical routine, we remove drains when the daily drainage volume falls below 100 cc. In CA, the drainage volume increases, and milky fluid begins to be observed. This increased daily drain volume in the postoperative period can guide the management of chylous ascites. In our study, the mean drain volume in patients with CA on days 1 and 4 was significantly greater than that in patients without CA (650/450 vs. 830/650).\u0026nbsp;Concurrently, the drain volume in patients who underwent TPN on day 4 exceeded 830 cc.\u0026nbsp;This value was greater than the average postoperative drainage volume (600 cc.) of the 4th day. Pearson correlation analysis revealed a significant, strong, positive correlation between the amount of drainage performed on the fourth postoperative day and the day that TPN was initiated (p=0.009). There was a similar positive correlation between the number of days TPN was administered and the number of days octreotide was administered (p=0.025).\u0026nbsp;For patients resistant to the chylous diet, both TPN and octreotide therapy were administered concurrently to facilitate faster recovery. Chylous ascites appeared on the 3rd day, and if the chylous diet was consumed, the drains were removed approximately on the 6th day. In the resistant group, the drains were removed on the 10th day of TPN and octreotide treatment. In other words, CA development was observed in patients whose drains were above 670 on day 4, and TPN use was observed in patients whose drains were above 830 cc. On day 4. In TPN users, octreotide use was observed to increase at the same time.\u003c/p\u003e\n\u003cp\u003eChylous ascites onset, the time to treatment, and recovery times for those using diet and TPN vary significantly among studies since the data of the studies depend on low case numbers or case reports. The time to onset of chylous ascites can range from 4--30 days, and recovery can range from 7--44 days in Solmaz’s study (5). Tan et al. (13) summarized the treatment management of 140 patients in a review of 16 studies. Accordingly, the time to onset of chylous ascites and resolution was 5–9 days for L/T and 3.5–8 days for L/S. Among the patients treated conservatively, 27% were treated with MCT, 52% with TPN, and 9% with TPN + MCT. The resolution was 12 days for MCT, 9 days for TPN, and 18 days for TPN + MCT. In our study, the onset of chylous ascites was 3 days, and the average resolution was 6 days. The resolution for MCT was 5 days, that for TPN was 9 days, and that for octreotide was 10 days. A total of 14.8% of the patients received TPN alone, and 11.5% of the patients received both TPN and octreotide. The remaining patients received only an MCT diet and recovered.\u003c/p\u003e\n\u003cp\u003eIn this study, those receiving octreotide treatment had lower globulin (p=0.048) and total protein levels (p=0.049). The same inverse relationship was also observed with the duration of octreotide administration (p=0.015). As globulin levels decreased, the duration of octreotide use increased. While albumin is a protein that is also lost in chylous ascites, it may be influenced by many factors and regulated by hepatic synthesis. However, the loss of immunoglobulins, which are a fraction of globulins produced by lymphatic leakage, may be associated with chylous ascites and increased octreotide requirements and may correlate with lymphatic leakage. Globulin levels may reflect losses in chylous ascites.\u003c/p\u003e\n\u003cp\u003eFinally, uncomplicated and treated CA does not affect survival or mortality. We found no correlation between CA and mortality. No correlation was found between different levels of lymphadenectomy, drainage volumes, or survival.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn the patients included in the study, postoperative drainage, total parenteral nutrition, octreotide, and dietary intervention were successfully managed. Postoperative chylous ascites is a rare complication of retroperitoneal surgery resulting from accidental disruption of major retroperitoneal lymphatics and may be associated with serious mechanical, nutritional, and immunological consequences due to the continuous loss of protein and lymphocytes. Various treatment regimens can be used successfully to treat chylous ascites. There is no standard management for chylous ascites after lymphadenectomy because there is little evidence from case series or expert opinion. Initially, medical and conservative treatment is recommended. In resistant patients, interventional management or surgical treatment may be recommended. The prognosis for patients with chylous ascites is generally good, and most patients respond to conservative measures. An individualized approach with multidisciplinary participation should always be taken. However, the best policy is to prevent chylous complications by carefully controlling the major lymphatics via meticulous dissection techniques and suture ligation during primary surgical intervention.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBaşakşehir \u0026Ccedil;am and Sakura City Hospital, Department of Gynecologic Oncology Surgery, Istanbul, T\u0026uuml;rkiye\u003c/p\u003e\n\u003cp\u003eTolga \u0026Ccedil;iftpınar\u003c/p\u003e\n\u003cp\u003eBaşakşehir \u0026Ccedil;am and Sakura City Hospital, Department of Gynecologic Oncology Surgery, Istanbul, T\u0026uuml;rkiye\u003c/p\u003e\n\u003cp\u003eAyşe Hazırbulan\u003c/p\u003e\n\u003cp\u003eBaşakşehir \u0026Ccedil;am and Sakura City Hospital, Department of Gynecologic Oncology Surgery, Istanbul, T\u0026uuml;rkiye\u003c/p\u003e\n\u003cp\u003eNil\u0026uuml;fer \u0026Ccedil;etinkaya Kocadal\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding author:\u003c/strong\u003e Tolga \u0026Ccedil;iftpınar\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ee-mail:\u0026nbsp;\u003c/strong\[email protected]\u003c/p\u003e\n\u003ch3\u003eEthics approval and consent to participate\u003c/h3\u003e\n\u003cp\u003eThe study was carried out by the Declaration of Helsinki, and the study protocol was approved by the hospital\u0026rsquo;s Local Ethics Committee with the acceptance number 13.12.2023.648. The participants were informed about the study objectives and methods, assured of data confidentiality, and provided written informed consent prior to participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo grant funding was utilized to conduct the research outlined in this document.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLeibovitch I. Postoperative chylous ascites--the urologist\u0026rsquo;s view. Drugs Today (Barc). 2002 Oct;38(10):687\u0026ndash;97\u003c/li\u003e\n\u003cli\u003eRose KM, Huelster HL, Roberts EC, Manley BJ, Gilbert SM, Sexton WJ. Contemporary Management of Chylous Ascites after Retroperitoneal Surgery: Development of an Evidence-Based Treatment Algorithm. J Urol. 2022 Jul;208(1):53-61. doi: 10.1097/JU.0000000000002494. Epub 2022 Feb 25. PMID: 35212572.\u003c/li\u003e\n\u003cli\u003eManolitsas TP, Abdessalam S, Fowler JM. Chylous ascites following treatment for gynecologic malignancies. Gynecol Oncol. 2002 Sep;86(3):370\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eHan D, Wu X, Li J, Ke G. Postoperative chylous ascites in patients with gynecologic malignancies. Int J Gynecol Cancer. 2012;22: 186\u0026ndash;190.\u003c/li\u003e\n\u003cli\u003eSolmaz U, Turan V, Mat E, et al.: Chylous ascites following retroperitoneal lymphadenectomy in gynecologic malignancies: Incidence, risk factors and management. Int J Surg 2015;16:88\u0026ndash;93\u003c/li\u003e\n\u003cli\u003eA review of the postoperative lymphatic leakage Shulan Lv1,*, Qing Wang1,*, Wanqiu Zhao2,*, Lu Han1, Qi Wang1, Nasra Batchu1, Qurat Ulain1, Junkai Zou1, Chao Sun1, Jiang Du1, Qing Song1,3,4 and Qiling Li1,4\u003c/li\u003e\n\u003cli\u003eQi Z, Zhang Y. Rare case of concurrent severe chylous ascites after radical surgery for cervical cancer. Eur J Gynecol Oncol. 2015;36(3):356-8. PMID: 26189272.\u003c/li\u003e\n\u003cli\u003eAalami OO, Allen DB, Organ CH Jr. Chylous ascites: a collective review. Surgery. 2000 Nov;128(5):761-78. doi: 10.1067/msy.2000.109502. PMID: 11056439.\u003c/li\u003e\n\u003cli\u003eZhao Y, Hu W, Hou X, et al.: Chylous ascites after laparoscopic lymph node dissection in gynecologic malignancies. J Minim Invasive Gynecol 2014;21:90\u0026ndash;96.\u003c/li\u003e\n\u003cli\u003eThiel FC, Parvanta P, Hein A et al: Chylous ascites after lymphadenectomy for gynecological malignancies. J Surg Oncol 2016; 114: 613.\u003c/li\u003e\n\u003cli\u003eZhu H, Zou J, Pan H, Huang Y, Chi P. Comparison of laparoscopic versus robot-assisted sugery for rectal cancer after neo-adjuvant therapy: a large volume single center experience. BMC Surg. 2025 Mar 12;25(1):98. doi: 10.1186/s12893-025-02764-5. PMID: 40075413; PMCID: PMC11899483.\u003c/li\u003e\n\u003cli\u003eTulunay G, Ureyen I, Turan T, Karalok A, Kavak D, Ozgul N, Ocalan R, Tapisiz OL, Boran N, Kose MF. Chylous ascites: analysis of 24 patients. Gynecol Oncol. 2012 Oct;127(1):191-7. doi: 10.1016/j.ygyno.2012.06.023. Epub 2012 Jun 21. PMID: 22728517.\u003c/li\u003e\n\u003cli\u003eTan X, Luo G, Liao G, Liao H. Postoperative Chylous Ascites in Gynecological Malignancies: Two Case Reports and a Literature Review. Obstet Gynecol Int. 2024 Jun 25;2024:1810634. doi: 10.1155/2024/1810634. PMID: 38957414; PMCID: PMC11219204.\u003c/li\u003e\n\u003cli\u003eWilliams C, Petignat P, Alobaid A, Provencher D, Gauthier P. Chylous ascites after pelvic lymph node dissection for gynecologic cancer. Eur J Surg Oncol. 2007 Apr;33(3):399-400. doi: 10.1016/j.ejso.2006.03.045. Epub 2006 May 8. PMID: 16682167.\u003c/li\u003e\n\u003cli\u003eKim PH, Tsauo J, Shin JH. Lymphangiography with or without Embolization for the Treatment of Postoperative Chylous Ascites. Ann Vasc Surg. 2020 Oct;68:351-360. doi: 10.1016/j.avsg.2020.04.063. Epub 2020 May 19. PMID: 32439520.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Chylous ascites, gynecological malignancy, lymphadenectomy, drain volume","lastPublishedDoi":"10.21203/rs.3.rs-7665070/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7665070/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective: \u003c/strong\u003eChylous ascites developing in the abdomen after lymphadenectomy in patients with gynecological malignancies is a rare complication. In this study, we attempted to establish a standard approach for the management of chylous ascites on the basis of our clinical experience. The diagnosis, management, and possible outcomes of chylous ascites were evaluated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and Methods: \u003c/strong\u003eBetween 2020 and 2024, 867 patients who underwent lymphadenectomy for gynecological malignancies at the Gynecological Oncology Clinic of Başakşehir Çam and Sakura City Hospital were retrospectively examined.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eChylous ascites (CA) developed in 61 (7%) of 867 patients after surgery. The mean age was 55 years, the body mass index was 31, and the mean hospitalization duration was 10 days. All patients underwent retroperitoneal lymphatic dissection. Paraaortic lymph node dissection was performed in 95.1% of the patients. In 32 of the patients (52.5%) with CA, lymphadenectomy was performed up to the level of the left renal vein. All patients who developed CA were treated with conservative management. A medium-chain triglyceride (MCT) diet was started in all patients. Nine patients (14.8%) started total parenteral nutrition (TPN), and 7 patients (11.5%) used octreotide. Patients with CA had greater drain volumes than those without CA, and patients who started TPN and octreotide had greater drain volumes than those who received only MCT. TPN and octreotide users also had longer hospital stays.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThe mean drainage volumes on postoperative days 1 and 4 were significantly greater in patients with chylous ascites than in those without chylous ascites (650/450 vs. 830/650). There was a significant, strong, and positive correlation between the amount of drainage on the fourth day and the day that the TPN started according to the Pearson correlation analysis (p=0.009).\u003c/p\u003e","manuscriptTitle":"Management of Chylous Acid in Gynecological Malignancies","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-28 03:09:06","doi":"10.21203/rs.3.rs-7665070/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"294406283669354850178792529043907927378","date":"2026-05-19T00:42:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"62969025466203362207417200953308866193","date":"2026-05-18T15:43:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"80211459257876937772574580748111381376","date":"2026-05-18T10:10:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"10193067630754124615170134760752007092","date":"2026-05-07T09:46:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-25T09:09:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"292856199270142369908791144440159786756","date":"2026-01-24T15:01:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-22T14:25:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-29T10:11:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-23T10:10:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-22T12:20:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-09-20T15:18:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9c092c03-f9ce-4a92-8cf3-5417665e974c","owner":[],"postedDate":"January 28th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"294406283669354850178792529043907927378","date":"2026-05-19T00:42:47+00:00","index":145,"fulltext":""},{"type":"reviewerAgreed","content":"62969025466203362207417200953308866193","date":"2026-05-18T15:43:33+00:00","index":144,"fulltext":""},{"type":"reviewerAgreed","content":"80211459257876937772574580748111381376","date":"2026-05-18T10:10:46+00:00","index":142,"fulltext":""},{"type":"reviewerAgreed","content":"10193067630754124615170134760752007092","date":"2026-05-07T09:46:35+00:00","index":114,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":61709631,"name":"Biological sciences/Cancer"},{"id":61709632,"name":"Health sciences/Diseases"},{"id":61709633,"name":"Health sciences/Gastroenterology"},{"id":61709634,"name":"Health sciences/Medical research"},{"id":61709635,"name":"Health sciences/Oncology"}],"tags":[],"updatedAt":"2026-01-28T03:09:07+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-28 03:09:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7665070","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7665070","identity":"rs-7665070","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}