Retrospective Study
Copyright ©The Author(s) 2025. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Mar 16, 2025; 13(8): 97887
Published online Mar 16, 2025. doi: 10.12998/wjcc.v13.i8.97887
Chyle leak following root of mesentery dissection in pancreaticoduodenectomy with inferior infracolic superior mesenteric artery first approach
Prabir Maharjan, Sujan Regmee, Spandan D Adhikari, Rabin Pahari, Roshan Ghimire, Dhiresh K Maharjan, Suman K Shrestha, Prabin B Thapa
Prabir Maharjan, Sujan Regmee, Spandan D Adhikari, Rabin Pahari, Roshan Ghimire, Dhiresh K Maharjan, Suman K Shrestha, Prabin B Thapa, Department of Gastrointestinal and General Surgery, Kathmandu Medical College and Teaching Hospital, Kathmandu 44600, Nepal
Author contributions: Maharjan P, Regmee S, Adhikari SD, Pahari R, Ghimire R, Maharjan DK, Shrestha SK, and Thapa PB contributed to the conceptualization of the study; Maharjan P and Regmee S contributed to the data curation; Maharjan P, Adhikari SD, and Pahari R contributed to the formal analysis; Maharjan P, Regmee S, Ghimire R, Maharjan DK, and Thapa PB performed the methodology; Maharjan P, Regmee S, and Shrestha SK contributed to the project administration; Maharjan P and Ghimire R contributed to the resourcing; Maharjan P and Regmee S provided software expertise; Maharjan P, Ghimire R, Maharjan DK, and Thapa PB contributed to the supervision of the study; Maharjan P, Regmee S, Ghimire R, Maharjan DK, and Thapa PB contributed to the writing, review, and editing of the manuscript; and all authors read and approved the final manuscript.
Institutional review board statement: This study was reviewed and approved by the Kathmandu Medical College Institutional Review Committee, approval Ref: 25032024/02.
Informed consent statement: All study participants, or their legal guardians, provided informed consent prior to study enrollment.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: Participants gave informed consent for data sharing. No additional data available apart from the mentioned data.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Prabir Maharjan, Department of Gastrointestinal and General Surgery, Kathmandu Medical College and Teaching Hospital, Sinamangal, Kathmandu 44600, Nepal. prabirstx493@kmc.edu.np
Received: June 12, 2024
Revised: November 2, 2024
Accepted: November 20, 2024
Published online: March 16, 2025
Processing time: 174 Days and 22.5 Hours
Abstract
BACKGROUND

The root of mesentery dissection is one of the critical maneuvers, especially in borderline resectable pancreatic head cancer. Intra-abdominal chyle leak (CL) including chylous ascites may ensue in up to 10% of patients after pancreatic resections. Globally recognized superior mesenteric artery (SMA) first approaches are invariably performed. The mesenteric dissection through the inferior infracolic approach has been discussed in this study emphasizing its post-operative impact on CL which is the cornerstone of this study.

AIM

To assess incidence, risk factors, clinical impact of CL following root of mesentery dissection, and the different treatment modalities.

METHODS

This is a retrospective study incorporating the patients who underwent dissection of the root of mesentery with inferior infracolic SMA first approach pancreatoduodenectomy for the ventral body and uncinate mass of pancreas in the Department of Gastrointestinal and General Surgery of Kathmandu Medical College and Teaching Hospital from January 1, 2021 to February 28, 2024. Intraoperative findings and postoperative outcomes were analyzed.

RESULTS

In three years, ten patients underwent root of mesentery dissection with inferior infracolic SMA first approach pancreatoduodenectomy. The mean age was 67.6 years with a male-to-female ratio of 4:5. CL was seen in four patients. With virtue of CL, Clavien-Dindo grade II or higher morbidity was observed in four patients. Two patients had a hospital stay of more than 20 days with the former having a delayed gastric emptying and the latter with long-term total parenteral nutrition requirement. The mean operative time was 330 minutes. Curative resection was achieved in 100% of the patients. The mean duration of the intensive care unit and hospital stay were 2.55 ± 1.45 days and 15.7 ± 5.32 days, respectively.

CONCLUSION

Root of mesentery dissection with lymphadenectomy and vascular resection correlated with occurrence of CL. After complete curative resection, these were managed with total parenteral nutrition without adversely impacting outcome.

Keywords: Chyle leak; Chylous ascites; Clavien-Dindo; Pancreatoduodenectomy; Root of mesentery dissection; Superior mesenteric artery first approach; Total parenteral nutrition; Uncinate mass; Vascular resection; Ventral body mass

Core Tip: Pancreatoduodenectomy is invariably discussed in terms of its weightage of surgery and frequent complications like post-operative pancreatic fistula, post-pancreatectomy hemorrhage, and delayed gastric emptying. However, chyle leak is rarely discussed. This article is a testament to the outcomes of the root of mesentery dissection with the virtue of achieving complete oncological resection. This article discusses the incidence, clinical impact, and risk factors of chyle leak following the root of mesentery dissection in pancreaticoduodenectomy, emphasizing effective management without re-exploration but utilizing total parenteral nutrition and dietary restrictions without adverse effect on the outcome.