S3507 A Case Report: Rare Case of Chyle Leak Status Post Robotic Assisted Cholecystectomy in the Setting of Diabetic Ketoacidosis

Introduction: A robotic-assisted cholecystectomy (RAC) is a minimally invasive procedure for removal of the gallbladder. Common complications include bile duct injury, sepsis and intestinal obstruction. One rare postoperative complication of cholecystectomy is a chyle leak. With there being only 8 current cases in literature, this report presents possibly the first RAC-associated chyle leak and discusses its associated history, findings, and treatment. Case Description/Methods: Sixty-five-year-old man presents to the emergency department roughly 6 days after an elective robotic assisted cholecystectomy (RAC) with severe abdominal pain, nausea, vomiting, and unable to keep anything down post-op. The patient was admitted to the hospital and was found to be in diabetic ketoacidosis associated with his history of Type 2 Diabetes Mellitus, requiring intensive care unit management. The patient underwent computerized tomography of abdomen and pelvis (CTAP), which illustrated bilateral pleural effusions as well as a large complex fluid collection in the gallbladder fossa despite the presence of a drain, raising concern for bile leak or abscess. In preparation of further workup, a nuclear medicine HIDA scan was performed to evaluate for the presence of a bile leak, which was negative. Previous studies indicate that chyle leak can be identified by triglyceride count greater than 110 mg/dL collected by the drain or by serum to drain triglyceride ratio. A CTAP scan was used to track the size of the abscess and the drain triglyceride content, which was found to be 127 mg/dL confirming suspicion for a chyle leak, an exceptionally rare complication of laparoscopic cholecystectomy and even more so for RAC. Discussion: The therapeutic goals outlined in current literature aligned with our treatment plan, with a focus on limiting lymphatic flow and replenishing lost nutrients, primarily through dietary adjustments (total parenteral nutrition (TPN) and a low-fat, high-protein diet) and pharmacological treatments. Moreover, as opposed to TPN alone, combining octreotide with TPN has been shown to shorten the time required for drain removal. If typical non-operative management is unsuccessful, treatment utilizing interventional radiology by ligation of the thoracic duct can be an alternative. In summary, studying chyle leak in patients after robotic-assisted cholecystectomy is essential for preventing complications, ensuring proper recovery, and refining surgical techniques to minimize risk in future procedures.