腹腔鏡根治性腎切除術後之併發症:乳糜腹水及隨後之持續性打嗝-病例報告

張乃文¹、王紹全^1,2,3

¹中山醫學大學附設醫院 泌尿科， ²醫學院， ³醫學研究所

Chylous ascites and subsequent persistent hiccup as complications after laparoscopic radical nephrectomy - A case report

Nai-Wen Chang¹, Shao-Chuan Wang^1,2,3

Department of Urology¹, School of Medicine² and Institute of Medicine³, Chung Shan Medical University Hospital, Taichung, Taiwan

Introduction: Chylous ascites is not a rare postoperative complication of laparoscopic nephrectomy. Persistent hiccup was defined as the duration of hiccups from 48 h to 1 month which can develop from psychological or idiopathic causes, leading to stimulation of the phrenic nerve and diaphragm. We presented a patient who developed chylous ascites and subsequent persistent hiccups as unusual complications after laparoscopic radical nephrectomy with lymph node dissection.

Case presentation: A 45-year-old male had history of gastric ulcer and gastroesophageal reflux disease, LA Grade A. He mentioned left flank discomfort when turning over on the bed in the recent six months. He was diagnosed as left renal cell carcinoma with renal vein thrombus and para-aortic lymph node, cT3N1M0, stage III. He started neoadjuvant immunotherapy with Pembrolizumab and target therapy with Sunitinib. There was no specific discomfort after fourth course of pembrolizumab. Abdominal CT showed residual left renal cell carcinoma with metastatic lymphadenopathies, partial response. Then, he received left nephrectomy with lymph node dissection. The pathology showed left renal cell carcinoma, fumarate hydratase-deficient type, ypT3aN1. On post operative day two, milky white drainage from Jason–Pratt (J-P) drain was noted and chylous ascites was confirmed later. The patient started to keep low fat diet. The drainage became lighter in three days. However, he suffered from intermittent hiccups, nausea and vomiting on post operative day six. KUB showed gastric bubble expanded. The patient kept NPO and we pulled out J-P drain 3 cm on post operative day nine. The hiccups improved mildly. The patient started to try diet gradually, but hiccups persisted. We removed J-P drain on post operative day 12 and the hiccups improved. The hiccup disappeared since post operative day 13.

Discussion: Chylous ascites developed more often in left than right nephrectomy and was higher in radical nephrectomy with lymphadenectomy than radical nephrectomy. Our patient was treated conservatively with low-fat diet successfully. However, considering the history of gastroesophageal reflux disease, we speculated the persistent hiccup was associated with stomach expansion related to the low-fat diet. We tried nonpharmacological treatments such as valsalva maneuver and pharmacological treatments including chlorpromazine and baclofen but in vain. Finally, we suspected the persistent hiccups may be related to stimulation of phrenic nerve caused by the J-P drain at left renal fossa because the hiccups disappeared after J-P drain removal.

Conclusion: Although chylous ascites and hiccup are not rare postoperative complications, respectively, recurrent hiccup following chylous ascites is an unusual sequential complication. If nonpharmacological and pharmacological treatments fail to treat persistent hiccup, we should consider remove J-P drain, the probable origin of stimulation, earlier if clinical permitted