Chyle leak following root of mesentery dissection in pancreaticoduodenectomy with inferior infracolic superior mesenteric artery first approach.

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.