Case Report
Hell J Surg. 2024 Oct-Dec;94(4):234–236
doi: 10.59869/24052
Panagiotis Theodorou, Spilios Spiliotopoulos, Konstantinos Saliaris, Evgenia Mela, Ioannis Moysidis, Alexandros Chamzin, Konstantinos Toutouzas
First Propaedeutic Department of Surgery, Hippocration General Hospital, National and Kapodistrian University of Athens, Athens, Greece
Correspondence: Panagiotis Theodorou, 114 Vasilissis Sofias St., Athens 11527, Greece, Tel.: +30 6942 425780, e-mail: panptheodorou@gmail.com
ABSTRACT
Introduction: Cholelithiasis is a very common condition that is usually safely managed by laparoscopic cholecystectomy (1,2). Chyle leak is a rare but potentially serious complication following abdominal surgery. We report a case of chyle leakage after elective laparoscopic cholecystectomy and review current literature regarding its prevalence, diagnosis and management of this complication.
Case report: We present a case of a 64-year-old male with chyle leak following elective laparoscopic cholecystectomy performed for symptomatic cholelithiasis. On the first postoperative day, chylous fluid was detected in the surgical drain. Biochemical analysis confirmed the diagnosis. The patient was successfully managed conservatively with dietary modifications.
Discussion: Chyle leaks are rarely reported following cholecystectomy. Conservative management is often effective, especially in low-output cases. Surgical intervention is reserved for persistent high-output leaks.
Conclusion: Early recognition and individualised treatment planning are crucial in managing chyle leaks after laparoscopic cholecystectomy.
Key Words: Chyle leak, chylous leakage, cholelithiasis, laparoscopic cholecystectomy, conservative management
Submission: 10.04.2025, Acceptance: 20.06.2025
INTRODUCTION
Cholelithiasis is highly prevalent in the Western world [1]. To date, no official national data on cholecystectomy procedures in Greece have been published by ELSTAT or any other governmental authority. Nevertheless, based on the expert opinion of a senior surgeon, it is estimated that approximately 20,000-30,000 cholecystectomies are performed annually in Greece [3]. This estimation is consistent with the surgical volume at our institution, the Hippokration General Hospital of Athens, where 1,000-1,500 cholecystectomies are performed annually. Laparoscopic cholecystectomy is considered the gold standard for treatment of cholecystitis or symptomatic cholelithiasis. Chylous leakage following this procedure is exceptionally rare, with only a few cases described in the literature. We present a case of postoperative chyle leak and provide a brief review of published evidence on its diagnosis and management.
CASE REPORT
A 64-year-old male was admitted for a scheduled laparoscopic cholecystectomy. Two months prior, he had been hospitalised for epigastric pain and vomiting and was diagnosed with gallstone-induced pancreatitis. The patient’s past medical history was free, without any chronic medication or any other previous surgery. Laboratory tests revealed leukocytosis (15,920/uL), elevated serum amylase (1,769 U/L), increased γGT (361 U/L), SGOT (81U/L), and SGPT (107 U/L). Total bilirubin was slightly elevated at 1.8 mg/dL, with direct bilirubin at 0.8 mg/dL. Abdominal ultrasound showed gallstones without signs of inflammation and a normal common bile duct diameter. MRCP confirmed cholelithiasis, without choledocholithiasis, and demonstrated mild blurring of the pancreatic parenchyma. The patient was managed conservatively with analgesics, hydration, and a light diet. No evidence of organ dysfunction or systemic inflammatory response syndrome (SIRS) was observed during the patient’s clinical course (mild pancreatitis – Atlanta Classification). His condition improved, and he was discharged after eight days with a recommendation for elective surgery. The primary reason for the patient’s eight-day hospitalisation was pain the fourth day, despite favorable clinical and laboratory findings.
Preoperatively, he was asymptomatic and had normal laboratory values. During surgery, the cystic duct and artery were easily identified, dissected and ligated with Hem-o-lok clips following the critical view of safety (CVS). During dissection of the gallbladder, the gallbladder inadvertently perforated, and gall was suctioned. Minor bleeding from the liver bed was controlled with diathermy. A drain was placed in the subhepatic space.
The patient began oral fluid intake immediately after surgery and showed excellent clinical progress. On the first postoperative day, a small amount of milky fluid (80cc) was observed from the drain. Biochemical analysis revealed an elevated triglyceride concentration (1,601 mg/dL), compared to the patient’s baseline level of 53 mg/dL (normal reference range 50-150mg/dL), confirming the presence of a chyle leak. Inflammatory markers and liver function tests were within normal limits, and the patient was discharged with the drain in place, oral antibiotics (cefuroxime) and instructions for low-fat diet [6] and follow-up.
DISCUSSION
Prevalence
Chyle leak after laparoscopic cholecystectomy is exceedingly rare. Most reports involve leaks after oncologic or extensive retroperitoneal surgery. Literature reveals few published cases linked to cholecystectomy [4-7]. One patient developed a mild leak on the second postoperative day following cholecystectomy for acute cholecystitis and was managed conservatively with dietary modifications and intermediate-term abdominal drainage [5]. Another case reported high-volume chylous leakage (1,000–1,500 ml/day) after laparoscopic cholecystectomy. Lymphoscintigraphy revealed a chyle leak from the hepatic region, which was managed with laparoscopic ligation of the leaking lymphatic vessel and application of fibrin glue [6]. All the above cases and their respective management approaches are summarized in Table 1.
Diagnosis
Diagnosis relies on recognising characteristic milky drainage and confirming it biochemically. Triglyceride levels >110mg/dL in drain fluid are diagnostic. In our case, the diagnosis was straightforward based on visual characteristics and elevated triglycerides. Imaging with CT lymphangiography may help rule out other causes or identify lymphatic disruption.
Management
Several management strategies have been proposed, although there is a lack of controlled studies. In our case, continuous drainage and prophylactic antibiotic use were employed [8]. A low-fat diet with restricted long-chain triglycerides is also recommended to reduce intestinal lymph flow [6]. Additionally, pancreatic lipase inhibitors [8] and somatostatin analogs [9] have been proposed [10]. There are no standard surgical guidelines for managing chyle leak post-cholecystectomy. However, surgical intervention may be considered for persistent, high-output leaks (>500 ml/day), especially when dietary restriction fails. Lymphoscintigraphy-confirmed leaks are often severe and may require surgery [5,8].
Upon reevaluation seven days later, there was no further drainage, and the drain was removed. The favorable clinical course supported a conservative management approach with good outcomes. The exact origin of the chyle leak remains unclear. Literature suggests it may result from iatrogenic injury, enzymatic damage, or transient mechanical pressure on lymphatics due to pancreatic inflammation [11]. In our case, pancreatitis was resolved two months earlier, and the drained fluid had low amylase (40 U/L), making a pancreatitis-related cause unlikely.
Literature Review Methodology
We searched PubMed and Scopus using the terms “chyle leak”, “chylous ascites”, “chylous leakage”, “cholecystectomy” and “laparoscopic cholecystectomy” for articles published in English language from 1990 to 2025.
CONCLUSION
Chyle leak is a rare complication following laparoscopic cholecystectomy. Literature on its management is limited. Early diagnosis is the key to favorable outcomes. Recognition of severity and individualisation, most commonly conservative treatment with drainage and dietary interventions appears to be the most appropriate initial strategy, while surgical intervention is reserved for high-output, persistent cases.
ACKNOWLEDGEMENTS
None.
ETHICAL STANDARDS DECLARATION
Ethical approval was not required, due to the nature of this study.
CONFLICTS OF INTEREST
All authors declare no conflicts of interest.
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