Somatostatin

Abstract

No therapeutic response: case report A 46-year-old man exhibited no response while receiving treatment with somatostatin for chylous ascites. The man underwent extracorporeal shock wave lithotripsy (ESWL) twice for a renal stone, which resulted in chronic pain. After ESWL, he was diagnosed with left pheochromocytoma metastasised from lung cancer requiring left laparoscopic adrenalectomy. On post-operative day (POD) 3, he was diagnosed with chylous ascites and resultant hypoalbuminaemia. He received total parenteral standard nutrition, including dextrose, amino acid, sodium, potassium and other electrolyte. Additionally, he received soya-oil emulsion/medium chain triglyceride/olive oil/fish oil [Smoflipid] as a substitute nutrition source. He also received conservative treatment with somatostatin [somatostatin acetate] 6mg daily [route not stated] for chylous ascites. Due to the high drainage amount, abdominal CT showed intra-abdominal fluid accumulation. The radiologist then tried intranodal lymphangiography with echo-guided puncturing of the lateral superficial circumflex iliac artery lymph nodes to inject ethiodized oil [lipiodol]. However, the attempt to identify the extravasated ethiodized oil failed. After 45 days of conservative treatment with somatostatin therapy, no response was noted. Therefore, the surgical treatment was planned. The man was admitted to the hospital and underwent midline laparotomy to approach the hilum region. However, persistent milky chylous leaking presented intraoperatively. Due to the possibility of microvascular anastomosis for a more physiological drainage of the leaking chylous, it was decided to bypass the chylous into venous system using microsurgical approach. He subsequently underwent lymphaticovenous anastomosis with side to end anastomosis fashion. After anastomosis, the flow from the chylous was found to be strong and the leaking was found to be significantly reduced intraoperatively. However, the fever and leucocytosis with left shifting in combination with an elevated CRP persisted. He was treated with prophylactic antibacterials [antibiotics]. After POD 6, his general condition became stable without fever or leucocytosis. The intra-abdominal drainage amount also started to decrease. A liquid diet was initially provided, which was then shifted to a mid-chain diet thereafter under a stable condition. The total parenteral nutrition was gradually tapered and successfully discontinued on POD 23. He was finally discharged on POD 30 without any drainage tube. Subsequently, he received treatment for the lung cancer and was also continuously followed in the clinic for 10 months without further development or treatment required for chylous ascites.