Successful Treatment of Congenital Chyloperitoneum with Platelet-Rich Fibrin Glue
The patient, a 5-days old boy, with a huge intra abdominal mass was operated and a very big mesenteric cyst situated on small intestine, without significant gastrointestinal tract involvement, was found and excised. On the 6th post operative day, by starting oral feeding, his abdomen became distended gradually. The abdominal ultrasonography revealed massive intra abdominal free fluid. Aspirating and laboratory tests marked that milky fluid to be chyle.\nNil per os (NPO) and total parenteral nutrition (TPN) was ordered and somatostatin analogue started at 11th day of life and was continued for about 2 weeks. However, upon restarting the oral feeding with medium chain triglycerides the abdomen started to distend again and therefore he was referred to our tertiary care center.\nThe patient was reevaluated and hyponatremia (Na 120mmol/L), hypokalemia (K 2.3mmol/L), as well as hypoalbuminemia (Alb 1.4g/dl) were corrected. Other laboratory tests were as follow: TG(abdominal fluid) 260mg/dl; Chol(abdominal fluid) 150mg/dl; TG(plasma) 65mg/dl; Chol(plasma) 100mg/dl; AST 40U/L; ALT 32U/L.\nA central vein catheter was placed and PPN started plus oral feeding with medium chain triglycerides. After one week intra abdominal fluid volume showed no change. Hence oral feeding ceased and thereafter the rate of fluid administration during the 2nd week of management was reduced. Abdominal re-exploration and placing of an intra abdominal catheter for eventual fluid aspiration was decided. A silicone catheter was inserted at the mesentery alignment since lymph leakage all over the small intestinal mesentery was observed.\nAlthough the patient received PPN for 2 weeks after the operation, 30-50 ml lymph was accumulating daily in the peritoneal cavity. It had been impossible to perform any kind of surgical procedure because of the widespread leakage of fluid considering his general condition. Fibrin glue as a final step of treatment was considered.\nA home-made PRFG was prepared (aprotinin was not used for avoiding probable anaphylactic shock[ and viral inactivation also was done in process of PRFG preparation). After taking 400 ml peripheral blood from ABO matched donor into commercial 450 ml triple blood donation bags and passing all viral safety tests according to blood transfusion regulation, platelets and fibrin glue were prepared according to standard procedures[. The platelets were prepared by first centrifugation at 2000×g for 2 min and then second centrifugation at 4000×g for 8 min and the supernatant plasma was separated and 15 ml platelet rich plasma was left. The fibrinogen concentrate was prepared from separated plasma by cryoprecipitating method. Following a -70°C freeze and a 4°C thaw, plasma was centrifuged at 6500×g for 5 minutes. The supernatant plasma was removed to a final volume of 15 ml, and 15 ml concentrated fibrinogen mixed with platelets (final volume 30 ml). One mililiter of thrombin was prepared from removed plasma by adding 10% calcium gluconate. When using, 30 ml PRFG was mixed with 1 ml thrombin and calcium gluconate and applied by infusion through the already placed abdominal catheter that was repositioned in various postures[. Twenty four hours after the PRFG infusion the controlled abdominal ultrasonography (AUS) revealed some fluid containing cysts around the small intestinal mesentery (ranging in size from 1cm to 3 cm) without any free intra peritoneal fluids.\nFive days after the infusion oral feeding (medium chain triglycerides) was re-started. The second follow up AUS on the 6th post infusion day was similar to the first one. On the 10th day, the patient was breastfed complemented with formula and the AUS revealed small cysts (maximum size of 1 cm) all around mesentery without any intra abdominal free fluid. The daily intra abdominal catheter excretion was about 5 ml of clear fluid.\nThe patient was discharged with the catheter placed and a mixed diet of breast feeding and formula with gradual reducing its ratio to the former. One month later he was fed only with breast milk, no secretion through the catheter was observed, and AUS was completely normal. Hence the catheter was removed.