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Refractory ascites after laparoscopic cholecystectomy: a case report.

Xiaoyun Cheng¹, Jin Huang², Aiming Yang¹

¹Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.

|August 17, 2022

Summary

Massive ascites after laparoscopic cholecystectomy, though rare, can result from lymphatic injury. Surgical intervention effectively treated a patient unresponsive to conservative management for this complication.

Keywords:

Case report Chylous leakage Laparoscopic cholecystectomy Lymphatic vessels Lymphoscintigraphy Refractory ascites

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Area of Science:

Gastroenterology
Surgical Oncology
Abdominal Surgery

Background:

Laparoscopic cholecystectomy is a standard procedure for gallstones, typically associated with minimal complications.
Ascites post-cholecystectomy is uncommon, particularly in patients without pre-existing liver dysfunction.
Refractory ascites following laparoscopic cholecystectomy in patients without liver disease is exceptionally rare.

Observation:

A 63-year-old woman presented with abdominal distension 12 days post-laparoscopic cholecystectomy.
She developed spontaneous bacterial peritonitis, decreased urine output, and significant daily ascites (1500-2000 ml).
Initial conservative treatments including diuretics, paracentesis, albumin, antibiotics, and vasodilators were ineffective.

Findings:

Abdominal CT confirmed massive effusion; ascitic fluid analysis showed a high serum-ascites albumin gradient (SAAG).
Lymphoscintigraphy identified a lymphatic leak into the abdominal cavity.
Surgical ligation of the identified lymphatic leak resolved the ascites, leading to patient recovery.

Implications:

Lymphoscintigraphy is crucial for diagnosing atypical chylous ascites, aiding in localization and qualification.
Surgical treatment should be considered for refractory ascites post-laparoscopic cholecystectomy when conservative measures fail.
This case highlights the importance of considering lymphatic injury in unexplained massive ascites after gallbladder surgery.