chylous ascites is a rare clinical condition that occurs as a consequence of disruption of the abdominal lymphatics . multiple causes have been described in the literature , including abdominal surgery , malignant neoplasms ( the most common cause in adults ) , blunt abdominal trauma , spontaneous bacterial peritonitis , cirrhosis , pelvic irradiation , peritoneal dialysis , abdominal tuberculosis , and congenital defects in lacteal formation . laparoscopic surgery for gastroesophageal reflux is now second only to biliary tract surgery in the frequency of minimally invasive procedures performed in everyday surgical practice . the main benefits of this approach are the reduction of wound - related morbidity , the short hospital stay , and the quicker return to full activity . the most common complications after laparoscopic fundoplication ( lf ) are pneumothorax , pneumomediastinum , esophageal or gastric perforation , bleeding , and even mesenteric thrombosis . herein , we discuss an uncommon complication that has been reported only twice in the literature . a 67-year - old woman with intense esophagitis ( grade iii of savary ) and a mild hiatal hernia underwent a laparoscopic nissen fundoplication in february 2000 . her most important clinical symptoms were retrosternal pain , acid and food regurgitation , and heartburn . no problems or difficulties occurred during the procedure . at laparoscopy , no abnormality was found . a hook electrocautery was used for dissecting the diaphragmatic crura and opening the retroesophageal window . diffuse ascites was also confirmed by an ultrasound examination . a paracentesis was performed and showed a white - milky odorless fluid with a specific gravity of 1.030 , sodium 135 meq / l , potassium 3.6 meq / l , total protein 4.4 g / l , amylase 25 u / l , triglycerides 1024 ng / dl , cholesterol 241 ng / dl , red blood cell count of 3450 , and white blood cell count of 2150 ( 70% lymphocytes ) . the central line was removed on day 20 and oral fat - free diet restarted . the anatomic relationship between the thoracic duct and esophagus shows that although lymphatic injury is a possible complication of a nissen - type fundoplication , it should be rare . the lumbar , intestinal , liver , and inferior intercostal lymphatics drain into the cisterna chyli ( anterior to the second lumbar vertebra ) , which is located between the origin of the abdominal aorta and azygos vein and is also located posterior to the right crus of the diaphragm . this collectively forms the thoracic duct , which passes through the aortic hiatus and courses in the right posterior mediastinum cephalad to the junction of the left subclavian and left internal jugular veins , where it empties . lymphatic channels in the abdomen follow the course of the blood vessels , and after passing through numerous lymph nodes , come together to form the thoracic duct . recent studies have shown that a true cisterna chyli is absent from most dissections and the thoracic duct is formed directly by the collecting lymphatic channels . the thoracic duct carries lymphatic drainage from all of the body except the right side of the head and neck , right arm , and right side of the thorax . fifty to 90% of the thoracic duct lymph is derived from intestinal and hepatic lymphatics . blalock performed thoracic duct occlusion experiments and concluded that thoracic duct obstruction alone was not sufficient to cause chylous ascites . patients with limited - reserve anastomotic channels are more at risk of developing persistent effusions / ascites when obstruction or division of lymphatic channels occurs . lymph is usually colorless , but when it leaves the small bowel it is saturated with minute particles of fat ( chylomicrons ) . paracentesis and fluid examination are essential in the diagnosis of chylous ascites . specific gravity greater than 1.012 , total protein greater than 30 normal lymph flow through the thoracic duct averages 1.0 ml / kg per hour and may be as high as 200 ml / kg per hour after a fatty meal . medium - chain triglycerides are absorbed directly into the portal venous system , bypassing the lymph system and reducing the amount and flow of chyle . postoperative chylous ascites is a rare complication after several retroperitoneal operations , such as lymphadenectomy , pancreaticoduodenectomy , distal spleen - renal shunt , and aortic surgery . these patients need aggressive treatment , and peritoneovenous shunting may be needed to maintain nutritional integrity . parys and hart reported a case of a 22-month - old girl who developed chylous ascites 3 weeks after an open nissen fundoplication . al - mousawi and abu - nema reported a case of chylous ascites after truncal vagotomy . they concluded that chylous ascites occurred because of an injury to an aberrant lymphatic trunk at the lower end of the esophagus . they describe the mechanism of lymphatic leakage as an injury of the cisterna chyli or thoracic duct during the retroesophageal dissection ( with scissors or monopolar dissection ) . alternatively , obstruction / injury of the thoracic duct may have happened when the posterior crura were sutured together . careful dissection in a correct plane behind the esophagus and minimal use of monopolar coagulation are the 2 most important measures for preventing this complication . surgical treatment is indicated in a patient when a surgically correctable lesion is present , persistence of symptoms are unresponsive to a low - fat , long - chain triglyceride diet after several months of parenteral nutrition has been instituted , and deterioration of clinical status has occurred in patients with undetermined causes . some authors advocate the use of isosulfan blue dye injected through foot lymphatics to identify the site of a leak during surgery . peritoneovenous shunts have been performed with variable reported success , and complications include occlusion , sepsis , and disseminated intravascular coagulation .
the accumulation of chylous fluid in the abdominal cavity is an infrequent , yet alarming , complication in abdominal surgery . 
 laparoscopic fundoplication has assumed a central role in the surgical treatment of gastroesophageal reflux disease and is significantly altering the balance of therapy toward more common and earlier surgical intervention . 
 we report the case of a 67-year - old woman with gastroesophageal reflux disease and intense esophagitis who underwent a laparoscopic nissen fundoplication in february 2000 . 
 the procedure was performed without apparent complications . 
 twenty days later , the patient complained of abdominal pain and distension . 
 ultrasonography showed ascites , whereas endoscopic and radiological exploration of the fundoplication demonstrated no abnormalities . 
 a paracentesis was performed , which showed a milky fluid with high concentrations of triglycerides ( 1024 ng / dl ) and cholesterol ( 241 ng / dl ) . 
 the patient was treated successfully with total parenteral nutrition for 3 weeks , followed by a low - fat diet . to our knowledge , this is the third reported case of chylous ascites after a nissen fundoplication and the second case after laparoscopic fundoplication . 
 the development of chylous ascites seems to be related to the injury of lymphatic vessels , including the thoracic duct , during the retroesophageal window dissection . 
 the careful dissection and judicious use of diathermy is proposed to prevent this rare complication .